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

[19]
[16]
injury and a urinary catheter is left in situ for 5-10 days . If a bladder injury is noted at the time of initial
dissection, it is recommended that the repair is undertaken at the time, with the help of a Urologist if
possible recommended. Surgery can of course be completed, and a check cystogram should be undertaken
on at least day 10 prior to removal of the catheter. It is important to consent all patients for the risk of
bladder injury prior to the operation.

Steps for managing inadvertent bladder injury at the time of TEP repair:

(1) Do not panic;
(2) Seek urology advice;
(3) Place an extra 12 mm port to aid in introducing 2/0 needles and suturing the bladder defect;
(4) Double layer repair with the introduction of a urinary catheter under the vision;
(5) 100 mL of saline used to inflate the bladder under vision to check a water-tight repair;
(6) Complete surgery and check cystogram after 10 days prior to catheter removal.

If a bladder injury is not recognised at the time of surgery patients will normally re-present early with severe
lower abdominal pain, haematuria, rising inflammatory markers, sepsis with CT imaging identifying pre
peritoneal fluid. It is very difficult to reattempt laparoscopic surgery, although not impossible, but a
laparotomy may be inevitable with subsequent bladder repair and urinary catheterization for 10 days.
Describing a spectrum of complications from TEP repairs this would be one of the more serious sequelae as
well as an unrecognized bowel complication requiring a laparotomy, normally as a result of an
unrecognised breach of the peritoneum, allowing small bowel to adhere to the mesh.

Mesh complications (bladder)
The use of prosthetic mesh is becoming increasingly common in hernia repairs, and therefore
complications with mesh migration or mesh erosion albeit rare, have also been reported. Both TAPP and
TEP hernia repairs are associated with mesh erosion into the bladder and can occur anywhere between 3
[20]
months to 10 years post-operatively . Cases of mesh erosion into the bladder usually require re-operation
and mesh removal, and in some cases a partial cystectomy, but this event is extremely rare and may be
associated with an increased risk if previous pelvic surgery has been undertaken prior to the hernia repair.

Chronic pain
Pain that persists for longer than 3 months after surgery and is defined as “chronic post-operative inguinal
pain (CPIP)”. It can be categorised as bothersome moderate pain impacting daily activities lasting at least 3
[6]
months post-operatively and decreasing over time . The incidence of chronic groin pain following TEP
repair is much less than an open repair [16,21] . Mesh fixation using staples or tacks, however, increases the risk
of chronic groin pain.

Patients that suffer complications are more likely to experience chronic groin pain. Although the chronic
pain incidence is low, there are potential consequences with neuropraxia to the ilioinguinal, iliohypogastric
nerves and even the genital branch of the genitofemoral nerve. The latter is one of the most commonly
affected nerves in laparoscopic surgery as well as the lateral cutaneous nerves of the thigh. Patients present
with an area of numbness just below the mid inguinal point on the thigh and should be managed with nerve
pain killers and physiotherapy. The lateral cutaneous nerves of the thigh are more likely to be injured if
dissection of the fascia is too close to these nerves laterally or by peeling the peritoneum too close to the
lateral muscles on initial dissection. The lateral cutaneous nerves can be seen in very thin patients and
should always be preserved with any subsequent damage presenting with pain on the lateral aspect of the