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Chapter 7
Worst Case Scenarios! Complications Related to Hernial
Disease
Ahmed Alwahab, Abdulrahman AlAwadhi,
Asmaa Abd Alwahab Nugud and
Shomous Abd Elwahab Nugud
Additional information is available at the end of the chapter
http://dx.doi.org/10.5772/intechopen.76079
© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
AhmedAlwahab, AbdulrahmanAlAwadhi,
Asmaa Abd AlwahabNugud and
Shomous Abd ElwahabNugud
Additional information is available at the end of the chapter
Abstract
Incarceration, obstruction and strangulation are well recognized common complications
of hernias. Several risk factors determine patients’ morbidity and mortality. Hernia sur-
gery complications encompass infections, fascial dehiscence, recurrence, neuralgia, vis-
ceral injury, and mesh erosion or migration predetermined by many risk factors. The
complications depend on the approach. Post-operative hernias are appreciated because
of their prevalence and complications. The criteria for enhanced recovery after surgery
depend on whether patient is in the pre-operative, intra-operative or post-operative
phase. Within the pediatric population, the risk of developing umbilical and inguinal is
variable.
Keywords: hernia, surgical complications, hernia surgery complications, recovery after
hernia surgery, post-surgical complications, watchful waiting, recurrence, endoscopic
approach, open approach
1. Introduction
hernial disease is among the oldest diseases described in the medical literature with reports as
old as 1500BC. It was not until the nineteenth century for the surgical approach to be recognized
as a treatment modality when Bassini published novel approach and primary outcomes. Since
© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
then, the improvements in surgical approach emphasized intended to reduce the long-term her-
nia recurrence and complications. The use of synthetic material for support was introduced in
the early 1900s by Handly by using silk for prosthetic support, but soon after it was found to
increase the incidence of wound infection [1]. Risk factors for hernia include, but are not limited
to, previous operations, physical stress, constipation, smoking, aging, trauma, family history,
systemic disease, and obesity. Hernia repair is among the most common surgeries performed
worldwide today, in which more than 75% found to be in the groin region, mainly inguinal
canal hernias [2, 3]. The overall risk of developing hernia in a lifespan is around 15% in males
and 5% in females, with proportionate increase in risk as the age increases. Inguinal hernias
any pathology that could lead to pain or mass formation in the groin area in particular. Such
diagnoses include, but not limited to, soft tissue, lymphoid tissue, associated vessels, bony struc-
tures, and reproductive organs [5, 6]. Even though hernias, in general, are associated with overall
promising short and long-term outcomes, there are still some complications to be recognized [7].
2. Complications of an untreated hernia
2.1. Incarceration and strangulation
Incarceration is the process by which hernia contents are trapped within a hernial sac in which
contents is compromised leading to ischemia and tissue necrosis, which is known as hernia
strangulation [8]. These two entities are complications of hernia itself and are associated with
increased rates of mortality and morbidity. The risk of incarceration and subsequent strangula-
9]
which might be partially due to weakening of the abdominal wall and decreased pressure
on the sac and its contents [9, 10]. Some of the risk factors for incarceration and subsequent
strangulation include advanced age at the time of presentation, femoral hernia, and recurrent
hernia [8]. Morbidity and mortality are determined by many factors including the patient age,
comorbidities, and duration of the strangulation, the longer the duration, the greater the stran-
gulation risk. For the reasons mentioned above along with an increased risk of perforation, a
strangulated hernia is considered a surgical emergency that mandates surgical intervention
resection may be warranted. In such scenarios, placement of prosthetic mesh is usually not
advised, as there will be a higher chance of bacterial translocation and wound infection [11, 12].
3. Complications of hernia surgery
3.1. Surgical complications
The incidence of complications associated with laparoscopic surgery is low on average when
compared with an open approach. Most of the serious complications occur during access
Hernia Surgery and Recent Developments94
to the abdominal cavity or while ports are created [13, ]. Chandler et al. [15] reported the
incidence of complications after laparoscopic surgery to be around 30 per 10,000, with half of
the small bowel, iliac artery, and colon; while the least injured organs were the bladder and
liver [15]. There is an increased risk of complications in patients with a history of previous
-
sive bowel resection, diaphragmatic hernia, and in patients with multiple cardiopulmonary
risks [16].
3.2. Infection (wound, UTI, pneumonia)
Despite the fact that in the modern era advanced aseptic measures have decreased the inci-
dence of post-operative infection; it is still a leading cause and a well-known complication
of hernia surgery. Infections could be from multiple sources including the suture used and/
or mesh. It is reported that infection incidences are as low as 1%, or even less, in multidisci-
plinary specialized hernia practice [17]. The most common underlying organisms are gram-
tissue are only involved, or deeper infection involving the mesh is there. Either way, should
such as mesh [18].
From a broader perspective, surgical site infections are seen in around 1% of clean wounds
and around 35% of contaminated wounds. Table 1
infections. Clinical features include erythema, induration, warmth, and frothy discharge later
in the course [19, 20]. The incidence of surgical wound infections can be reduced by following
and proper wound dressing [21].
3.3. Fascial dehiscence
strength. It can be seen early in the post-operative period, and it could also happen as a late
complication that might involve the full length of the surgical suture or part of it. Its incidence
improvement in the surgical techniques and wound management, the overall risk of fascial
dehiscence remains unchanged [2325].
related to surgical site and surgeons’ techniques. Patient risk factors include age, male gender,
ascites, chronic pulmonary disease, post-operative cough, obesity, malnutrition, and chronic
glucocorticoid therapy [19, 26]. Surgical technique risk factors include the length of the surgi-
cal wound if bigger than 18 cm or not. Suture failure is a major cause of fascial dehiscence,
and it is said that in around 95% of cases knots are intact, but they have been pulled through
the fascia resulting in fascial edge necrosis [27, 28].
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4. Hernia surgery complications
4.1. Recurrence
Recurrence of hernia is usually seen as a late complication of hernia surgery. When it occurs, it
-
sue ischemia. Early over-activity is a principal causative agent of recurrent hernia, as it results
hernia sac. OʼReilly et al. [29] found that patients who underwent a laparoscopic repair for an
inguinal hernia had a higher chance of having a recurrence in comparison to those who under-
similar clinical presentations such as seromas in the obliterated hernia sac [30]. Seroma can
seen after laparoscopic repair and are sometimes termed as a pseudo-hernia. Other etiologies
include hematomas that could be seen in anti-coagulated patients. They could be of a concern
if they were of large volume, as they could provide an optimal environment for bacterial
Depth of
infection
Comments
incisional
Infection occurs within 30 days after the surgery and involves skin and subcutaneous tissue
of the incision and encompasses the following criteria:
• Purulent discharge
• Isolated organism
•
Deep incisional Infection occurs within 30 days after the operation if there are no implants or within 1 year
from the surgery if there are implants. Infections are related to implanted prosthetic
material and involves deep fascial layers and muscle tissue, and encompass the following
criteria:
• Purulent discharge from deep tissue layer
• Deep incisional spontaneous dehiscence
•
•
Organ space Infection occurs within 30 days after the operation if there are no implants or within 1 year
from the surgery if there are implants. Infections are related to implanted prosthetic
and involve organs or anatomical spaces that were manipulated during surgery, and
encompass the following criteria:
• Purulent discharge from a drain
• Organisms isolated from suspected area
•
•
Table 1. Types and criteria for the diagnosis of surgical wound infection [22].
Hernia Surgery and Recent Developments96
growth and infection. Overall hematomas are far more common than seromas and both
could be prevented with a careful hemostasis during surgery [31]. One of the primary causes
-
-
Lichtenstein [7, 32].
Another factor to consider is the size of the initial hernia defect which is proposed propor-
tional to the risk of developing recurrence in the aftermath of hernia repair. This fact might
more ischemic in comparison to smaller sized defects. Isik et al. [33] found that higher levels
metalloproteinases-1-2-3 played an integral role in the formation of inguinal hernia, leading
33]. Other etiolo-
gies for hernia recurrence include complicated hernia at presentation such as incarceration or
for recurrence as the tissue is unhealthy, to begin with. Another causative agent for recur-
rence is smoking which is said to increase proteolytic enzymes and decrease protective factors
involved in tissue healing [11].
4.2. Neuralgia
Nerve injury could be a terrible consequence of an otherwise successful surgery presenting
with pain, loss of sensation or muscular weakness. Neuralgia, commonly known as post-
operative pain, is a rather common complication with varying degrees of pain after hernior-
after surgery, for the diagnosis of post-herniorrhaphy neuralgia to be made, pain should per-
, 35 -
-
genital branch of the genitofemoral nerve, while injuries to the lateral femorocutaneous nerve
is more common with laparoscopic approach, see Table 2 [1, 36].Most of the time, the mecha-
be prevented with careful handling of the tissue and preventing over manipulation of the
nerves. In laparoscopic approach staple placement below the iliopubic tract decreases the risk
of nerve entrapment [37].
oblique fascia. The genitofemoral nerve is thought to be injured following cord isolation for
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mesh tacking in the laparoscopic approach, which can be side stepped by avoiding tacking in
known areas of nerves distribution [1]. OʼReilly et al. [29] found that the risk for post-hernior-
compared with open approach [28].
-
-
it usually will fail improving the pain and may result in damaging more structures [15, 38].
4.3. Visceral injury
Bladder, testicular, and vas deferens injuries are among the commonly injured visceral organs
with groin herniorrhaphy procedures Among the least injured structures are the ureters
which are more often seen with the laparoscopic approach- the most common type of injury
is incomplete transection of the ureter and ureteral perforation [39]. Bladder injuries are
frequently reported with direct inguinal hernias, and in rare cases could result in a sliding
hernia, in which part of the bladder adheres to the hernia sac. Thus, direct sacs are usually
inverted back into the peritoneal cavity to avoid unnecessary dissection [, ].
Testicular swelling and atrophy could develop after inguinal hernia repair. Swelling and
edema of the scrotum are due to hematoma or edema of the inguinal canal that progress infe-
riorly to the scrotum with gravity. On one hand, testicular atrophy is associated with blood
supply injury during the process of dissection and isolation of the cord and usually is a painless
complication. On the other hand, testicular pain post-operatively could be a result of torsion
or abscess and ruling out such suspicion is done by ultrasound imaging. In the pediatric
Nerve Area afected
Ilioinguinal nerve •
• Mons pubis and Labia majora
• The root of the penis and upper scrotum
Iliohypogastric nerve • Skin of the hypogastric area
• Skin of the gluteal area
• Mons pubis and scrotum/labia
• Anterior lateral thigh area
Later femoral cutaneous nerve Anterior lateral thigh area
Femoral nerve • Motor nerve to quadriceps femoris
• Anterior thigh area
Table 2. Commonly injured nerves post-herniorrhaphy [1].
Hernia Surgery and Recent Developments98
population cord traction might cause testicular migration into the inguinal canal. Therefore,
before the end of the surgery testes are palpated to ensure the right placement [1, ].
Vas Deferens injury is considered a rare complication yet the most feared. However, if such
an injury was to happen, it requires an urgent urological consultation; injuries range from
as severe as transection to a mild laceration. Untreated injuries can result in the formation
of anti-sperm antibodies and infertility. Avoiding such dreaded complications is possible by
gentle traction of the vas and avoiding grasping or squeezing the Vas Deferens [21].
4.4. Mesh erosion\migration
Mesh migration or erosion may occur after femoral or inguinal hernias and depends on the
-
egorized into primary and secondary. Primary, also known as mechanical, is when the mesh
forces. While secondary, is the slow movement of the mesh through nearby anatomical struc-
tures due to body response to a foreign body. The result is an erosion of adjacent structures
such as the urinary bladder leading to urinary tract infections or hematuria, bowel injury and
, ].
hernia repair using an inter-peritoneal mesh. Animal studies showed that micro-erosions and
biological material such as collagen []. In addition, Leber [] reported a higher incidence
5. Post-operative hernia
Also known as an incisional hernia, post-operative hernias occur as a direct result of fascial
tissue failure to heal post laparotomy. Although incisional hernias are frequently seen either
post mid line and/or transverse incisions, it can, in theory, happen after any surgical incisions
like paramedian and McBurney incisions, and are also seen post laparoscopic surgeries [50].
Previously, the incidence was believed to be around 20%, but recent epidemiological studies
[5153]. Risk factors of incisional hernias are increased with advanced patient age, malnutri-
tion, immune-compromised state, smoking, and obesity [12, 15, , 55]. Other factors that play
an important role include emergency surgery and post-operative wound infection. One major
complication of incisional hernia repair surgery is a high recurrence rate, which might reach
up to 50%. In some cases this risk is related to the type of surgical approach, whether suture
repair or mesh supported repair, and also to the amount of tension applied on the wound
edges. Recurrence in this type of hernia is also related to the appearance of unrecognized
hernia sites [56]. Another set of complications is related to the empty hernia cavity that is left
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recommend placement of closed suction drainage; which by itself along with mesh will
increase the risk of infection post-operatively [57, 58].
6. Enhanced recovery after hernia surgery
The aim of enhanced recovery after surgery protocols is to improve outcomes, lower health
59, 60]. Such protocols
are evidence-based guidelines that include minimizing surgical trauma, post-operative pain,
stay and fasten the patient recovery [61]. Such approach to patient care should be a multi-
physical rehabilitation service, and most importantly patient cooperation [62, 63]. Patients
who are followed with an enhanced recovery protocol will have the same discharge criteria
will span through the full patient hospital stay; preoperatively, intra-operatively, and post-
operatively (Table 3) []. Before surgery, patient education and counseling about current
treatment options and best approach should be discussed. After that, a meticulous overview of
the patient general health condition and management of any comorbidities such as renal, car-
diac, or respiratory should be done. Intra-operatively prophylactic antibiotics are recommended
Period Criteria
Pre-operative • Patient education
• Medical comorbidities optimization
• Bowel preparation
Intra-operative •
•
• Thermal regulation
• Fluid maintenance
• Avoid drains and nasogastric tube
Post-operative • Enteral nutrition from day one post-operative
• Multimodal analgesia
•
• Early removal of urinary catheter
• Early mobilization
Table 3. Main criteria for enhanced recovery after surgery protocol [66].
Hernia Surgery and Recent Developments100
of the patient vital status [6567]. While post-operative period is mainly concerned with pain
68, 69].
7. Hernia and the pediatric population
7.1. Umbilical hernia
at birth in infants of Caucasian ethnicity and higher in those of African-American ethnicity,
for unknown reasons [1]. It is also more common in premature infants of all races, and some
less than 10% needing surgical intervention.
acquired not congenital with a male to female ratio of 3:1. The adult-type umbilical her-
nia usually will need surgical intervention for it to close and usually are symptomatic at
mass overlying the skin; long-standing untreated umbilical hernia might result in thinning
of covering skin and ulceration due to pressure necrosis of the adjacent skin. While small
umbilical hernias could pass unnoticed and discovered incidentally. This type of hernia is
type [3, 11, 70].
7.2. Inguinal hernias
Although the overall incidence of inguinal hernia in the pediatric population is low when
compared with adults, the complication that might arise is almost the same. In the age group,
bowel incarceration is incidence is low, but should this be the case, bowel infarction would
supply compromise leading to ischemic necrosis and testicular atrophy with an incidence
around 9% according to some studies [7173]. While in girls, ovarian torsion is reported to
happen with inguinal hernia strangulation in about third of patients with incarcerated hernia
-
gical intervention in this population [].
7.3. Congenital diaphragmatic hernia
The congenital diaphragmatic hernia is caused by a diaphragmatic defect resulting abdominal
distress so severe that it could be incompatible with life [75]. In many cases, this condition
Worst Case Scenarios! Complications Related to Hernial Disease
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101
can be diagnosed in utero via ultrasound, and for those not diagnosed prenatally, this condi-
tion should be suspected in neonates with respiratory distress and absent breath sounds soon
after delivery and can be easily diagnosed by chest X-ray [76]. Congenital diaphragmatic her-
nia complications are categorized into acute, and late-onset complications, the most serious
acute complication is persistent pulmonary hypertension of the new born other complications
complications includes chronic respiratory disease, recurrent hernia, spinal/chest wall abnor-
malities, neurological, and gastrointestinal complications [77, 78].
8. Watchful waiting vs. intervention in hernial disease
life, should it happen. Thus, many patients with asymptomatic hernias prefer to delay sur-
gical intervention until needed. As the natural history of an untreated hernia is generally
et al. [79] followed 720 men, half of which had a surgical intervention and half underwent
waiting was a suitable option to manage a minimally symptomatic inguinal hernia as the
overall risk of complication is low [80].
Author details
Ahmed Alwahab1,2*, Abdulrahman AlAwadhi1, Asmaa Abd Alwahab Nugud3 and
Shomous Abd Elwahab Nugud
*Address all correspondence to: a7md13@gmail.com
1 Dubai Health Authority, Dubai, UAE
2 Sharjah Institute for Medical Research, Sharjah, UAE
3 RAK Medical and Health Sciences University, RAK, UAE
Sharjah, UAE
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