Page 46 - World Journal of Laparoscopic Surgery

Snehal Fegade

The pressure in the preperitoneal space must be such as to the vas. A complete transaction of the vas needs to be repaired
offer sufficient resistance during trocar insertion to avoid in a young patient. An injury to the vas is best avoided and this
puncturing the peritoneum. may be done by identifying before dividing any structure near
the deep ring or floor of the extraperitoneal space. Also the
Correct Identification of the Anatomical Landmarks separation of cord structures from the hernial sac must be gentle
and direct; grasping of vas deferens with forceps must be
The next most important and crucial step in any hernia surgery avoided.
is the correct identification of anatomical landmarks. This is
difficult for beginners as the anatomy is different from that seen Pneumoperitoneum
in open surgery. The first most important step is to identify the
pubic bone. Once this is seen, the rest of the landmarks are It is a common occurrence in TEP which every surgeon should
traced keeping this as reference point. One is advised to keep be prepared to handle. Putting the patient in Trendelenburg
away from the triangle of doom, which contains the iliac vessels position and increasing the insufflation pressures to 15 mmHg
and to avoid placing tacks in the triangle of pain laterally. helps. If the problem still persists, a Veress needle can be inserted
at Palmer’s point. 4
Bladder Injuries
Postoperative Complications
Bladder injury most commonly occurs during port placement, Seroma/Hematoma Formation
dissecting a large direct sac or in a sliding hernia. It is mandatory
to empty the bladder prior to an inguinal hernia repair to avoid It is a common complication after laparoscopic hernia surgery,
a trocar injury. It is advisable that beginners catheterize the the incidence being in the range of 5-25%. They are specially
bladder during the initial part of their learning curve. The seen after large indirect hernia repair. Most resolve
diagnosis is evident when one sees urine in the extraperitoneal spontaneously over 4-6 weeks. A seroma can be avoided by
space. Repair is done with vicryl in two layers and a urinary minimizing dissection of the hernia sac from the cord structures,
catheter inserted for 7-10 days. 4 fixing the direct sac to pubic bone and fenestrating the
transversalis fascia in a direct hernia. Some surgeons put in a
Bowel Injuries drain if there is excessive bleeding or after extensive dissection.
Bowel injury is rare during hernia surgery. It can occur when Urinary Retention
reducing large hernias, inadvertent opening of peritoneum
causing the bowel to come into the field of surgery and in This complication after hernia repair has a reported incidence
reduction of sliding hernias. Injury is best avoided in such of 1.3 to 5.8%. It is usually precipitated in elderly patients,
circumstances by opening the hernial sac as close as possible especially if symptoms of prostatism are present. These patients
to the deep ring. The initial studies showed a higher incidence, are best catheterized prior to surgery and catheter removed the
especially with TAPP, but it decreased over time. 4 next day morning.

Vascular Injury Neuralgias
This is one of the commonest injuries occurring in hernia repair The incidence of this complication is reported to be between
and often a reason for conversion. The various sites where it 0.5 and 4.6% depending on the technique of repair. The
can occur is rectus muscle vessel injury during trocar insertion; intraperitoneal onlay mesh method had the highest incidence
inferior epigastric vessel injury; bleeding from venous plexus of neuralgias in one study and was hence abandoned as a form
on the pubic symphysis; aberrant obturator vein injury; of viable repair. The commonly involved nerves are lateral
testicular vessel injury; and the most disastrous of all, iliac cutaneous nerve of thigh, genitofemoral nerve and intermediate
vessels, which requires an emergency conversion to control cutaneous nerve of thigh. They are usually involved by mesh-
the bleeding and the immediate services of a vascular surgeon induced fibrosis or entrapment by a tack. The complication is
to repair the same. Most of the other bleeding can be controlled prevented by avoiding fixing the mesh lateral to the deep inguinal
with cautery or clips. Careful dissection and adherence to the ring in the region of the triangle of pain, safe dissection of a
principles of surgery will help in avoiding most of these injuries. 4 large hernial sac and no dissection of fascia over the psoas.

Injury to vas Deferens Testicular Pain and Swelling
Injury occurs while dissecting the hernia sac from the cord It occurs due to excessive dissection of a sac from the cord
structures. The injury causes an eventual fibrotic narrowing of structures, especially a complete sac. Reported incidence is of

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