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Alam et al. Mini-invasive Surg 2021;5:48 https://dx.doi.org/10.20517/2574-1225.2021.65 Page 3 of 8

or tissue glue. Glue or atraumatic mesh fixation has shown to have a lower risk of complications such as
[15]
nerve injury but especially both short- and long-term, chronic groin pain . The pre-peritoneum is then
[7,8]
reduced, and the skin is closed using absorbable sutures . Patients are usually discharged the same day or
the following day.

COMPLICATIONS
Immediate complications that are possible at the time of surgery include visceral injury (bowel and
bladder), vascular injury, injury to the vas deferens as well as the spermatic cords. Immediately after
surgery, patients can experience wound complications, bruising, scrotal swelling, seroma formation and
hematomas. Delayed or late complications include adhesions (to mesh as well as adhesional bowel
obstruction), fistula formation, testicular atrophy, nerve entrapment, and incisional hernia or a recurrence
as well as chronic pain [7,14,16] .

With seroma formation, urinary retention can also be a problem seen post hernia repair, but this is more
likely in older male patients secondary to prostatic hypertrophy. The incidence of post-operative urinary
retention varies from 1%-3% and other risk factors as well as increasing age > 60 years including a history of
[16]
benign prostatic hypertrophy, previous bladder neck surgery and an anaesthetic time of greater than 2 h .
The incidence of seroma formation following laparoscopic repair is 5%-7% and is more common following
dissection of both large indirect & direct hernias, especially L3 & M3 hernias (as per the EHS classification
of groin hernias). Seromas will often resolve with time and do not require aspiration unless there are signs
of infection or discomfort .
[16]

Peritoneal injuries
Incorrect placement of the balloon trocar or simply sometimes dissection of the hernial sac may result in a
breach of the peritoneum [Figure 1A], causing a pneumoperitoneum. Small peritoneal defects can be closed
using a variety of methods; suturing, the use of clips [Figure 1B], or Endoloops. Closing the peritoneal
defect avoids the loss of CO into the peritoneal cavity, and therefore allows the preperitoneal workspace to
2
be maintained.

Larger peritoneal tears essentially may force conversion to a TAPP repair, and thus is associated with the
risks of a TAPP including visceral injury, adhesions, and port site hernias .
[11]

Vascular injuries
Vascular injuries can occur with laparoscopic TEP repair as the inferior epigastric artery, external iliac
vessels, corona mortis as well as spermatic cord vessels are all exposed during surgery. Any vascular injury
occurring during hernia surgery can often lead to conversion to an open procedure albeit this is a rare
event. The inferior epigastric artery is the most frequently injured vessel, which can be damaged by balloon
dissection or using the camera to create the preperitoneal space [Figure 2A]. Most bleeding can be
controlled using clips or cautery. Inferior epigastric arteries can be ligated by the use of clips at the time of
surgery especially if inadvertently damaged, otherwise, there is always a risk of a significant retro-rectus
hematoma. If such a hematoma develops and it is not causing pain or discomfort, then simple monitoring is
adequate, otherwise surgical exploration may be required especially if acute and expanding, which can
involve further laparoscopy, or a laparotomy as needed. If an acute hematoma does require surgical
intervention, then it is recommended that the inferior epigastric vessels are ligated as these are the most
likely sources of the bleed.