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Page 6 of 8 Alam et al. Mini-invasive Surg 2021;5:48 https://dx.doi.org/10.20517/2574-1225.2021.65

affected thigh. Sometimes as a result of the use of traumatic fixation pain can also be caused in this area and
if the pain occurs immediately after surgery, it is recommended that the patients are taken back to the
theatre to remove the tacks. This manoeuvre does not avoid the complete effects of nerve damage, but it
may abate the severity of the injury.

Nerve injuries described above do require careful evaluation by a groin specialist, nerve mapping, magnetic
scan with neurography, with possible re-exploration and subsequent division of the nerves, but only after a
failure of nerve painkilling agents, and desensitisation treatments including physiotherapy.

Surgical emphysema
This can occur after surgery especially with the TEP procedure. The extraperitoneal space that is created can
allow gas to escape into this space further up the torso, with some patients experiencing even neck and facial
pain because they have surgical emphysema, which is easily palpable. This complication does disappear
eventually in time, reassurance and painkillers are all that is needed if the patient remains systemically well.
Patients should be able to carry on normal bodily functions, daily activities and early follow up in the clinic
after 5 to 7 days is all that is required.

DISCUSSION
Totally extraperitoneal repair for inguinal hernia remains a fast-growing procedure. It initially drove up the
cost of the operation. However, with increasing expertise, experience, utilisation of cost-effective resources
and most importantly its inception reducing the length of stay, recovery and return to normal activities has
overall provided patients and healthcare with good benefits. The main caveat with any hernia surgery is of
course the risk of complications and the TEP repair does rely on increasing expertise, with a recognised
[9]
steeper learning curve . Like any surgery, the consent process has profound implications on the direction a
surgeon wishes to steer their patients in terms of which operation they will choose. Options should though
always be given to patients especially with bilateral or recurrent hernia to undergo a minimally invasive
technique. This has been shown in international and NICE guidelines [9,22] . Understanding the caveats in any
surgical procedure are though profoundly important, especially in modern-day practice. The majority of
patients will thankfully not experience any serious complications however, the more common ones
associated with this repair would include umbilical wound infections, heavy bruising across the abdomen,
early surgical emphysema, penile and scrotal swelling for male patients, which all generally subside within
two to three weeks after the repair. Some patients will have debilitating seromas which require aspiration
but again these are few and far between. Any more serious complications such as identification of vascular
or bladder injuries at the time of surgery should be managed with at this time and by the utilization of
specialist expertise if required. An unrecognised bladder or bowel injury will present with abdominal pain,
sepsis, haematuria and rising inflammatory markers a few days after surgery. These are the most serious of
risks that all patients should be advised of as part of the consent process, but a bladder injury if recognized,
subsequently suture repaired with the placement of a urinary catheter should not cause undue long-term
harm to a patient other than the discomfort of a urinary catheter for 10 days. Rectus sheath hematomas are
managed conservatively with arterial embolization of any injury to the inferior epigastric artery rarely
required but remaining a possible feasible treatment modality.

Overall, the morbidity associated with the TEP inguinal repair operation is small with only 5%-10% of
patients experiencing a minor complication such as bruising, or wound infections, which all require
reassurance and monitoring. It is only the serious complications, which surgeons should be aware of and
their incidence is less than 0.5%.