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Nausea and vomiting
Intubation problems: Damage to
teeth/Sore throat/ laryngeal
Anaphylaxis/ idiosyncratic reactions
to anesthetic agents (malignant
CVS collapse and Respiratory
Hypothermia and Hypoxic brain
Awareness during anesthesia
Backache / Headache.
Electrical Burns = Perforated Organs
Complications Due To Pneumo
Shoulder Tip Pain
Injuries to the inferior epigastric vessels
Bleeding originating from the spermatic cord
Injury to the iliac artery occurred during clip fixation “triangle of
The distal aorta and right common iliac artery are particularly
prone to injury during trocar and port insertion in thin lean
Knowledge of laparoscopic anatomy
Placement of secondary cannulas under direct
vision with prior trans illumination of the
The decision to open must be made quickly if
the bleeding cannot be controlled
laparoscopically, and compression of the
bleeding site must be maintained with a
laparoscopic instrument while opening.
laparoscopic herniorrhaphy = 1.6% incidence of
neuralgias = open approaches
There are 6 nerves in the groin that your
surgeon is aware of and will avoid harm to.
Lateral femoral cutaneous nerve – =most common
nerve irritated= pain or hypersensitivity experienced
along the lateral thigh.
Genitofemoral nerve : Its irritation is usually
perceived by a hypersensitive scrotum in males and
hypersensitive labia majora in females. The femoral
branch innervates the anterior thigh, and irritation can
lead to pain or hypersensitivity of the upper anterior
Femoral nerve (and its anterior cutaneous branches) –
Rather rarely, it at risk to be irritated or injured by use
of a tack below the illio pubic tract. Even rarer, mesh
can irritate this nerve. If irritated or injured, leg
muscles may feel heavy or weak, or pain along the leg
Ilio hypogastric nerve – This nerve may only be
injured rarely during a laparoscopic repair if a tack
were to penetrate through the muscle and into the
nerve.Pain or hypersensitivity to the suprapubic
region or groin may occur.
Ilioinguinal nerve –Its injury during a
laparoscopic repair is extraordinarily rare.
Irritation causes pain or hypersensitivity to the
medial thigh, shaft of the penis, or groin
Paravasal nerve fibers (tiny nerves along the vas
deferens in a male) – irritation of these may cause
temporary testicular discomfort.
Knowledge of laparoscopic anatomy ( triangle of pain )
Avoidance of deep tacking in the abdominal wall muscles
mesh repairs that do not require fixation or have chosen
and correct placement ( don’t tack below the llliopubic tract)
The tract can be identified visually as a fibrous band at the
lower edge of the internal ring or manually by placing one’s
hand on the abdominal wall and palpating an instrument
placed laparoscopically at the level of the iliopubic tract.
If the surgeon cannot feel the instrument, the point of
contact of the probe is below the iliopubic tract. Because the
nerves usually enter the thigh below this line, placing
Injuries to the lateral cutaneous nerve and to
the genital branch of the genito-femoral nerve
can be minimized by using simple maneuvers.
Do not use abdominal wall counter pressure
when placing a tack
Dissect the abdominal wall meticulously and
try to identify obvious neural branches
Do not place and tack the Mesh under tension
Make all patients exercise starting the day after
the procedure [minimal exercise: a 1 to 3 miles,
Bowel injury is the third cause of death from a
laparoscopic procedure after major vascular injury and
Bowel injury is common during trocar insertion in a
patient with prior adhesions and during reducing an
incarcerated or strangulated hernia
Unlike major vascular injuries where the risk and
presentation are immediate, many bowel injuries go
unrecognized at the time of the procedure.
Consequently, patients present postoperatively, often
after discharge with peritonitis. This delay makes it a
significant cause of morbidity and mortality.
Urinary bladder injury is common during
reduction of direct hernias
the vas deferens injury is very rare = testicular
discomfort, infertility, or be completely
If the arterial supply to the testicle is divided
=ischemic orchitis and testicular atrophy= 0.36% of
primary hernias and 5% in recurrent ones.
If the venous blood supply from the testicle is
potentially compromised, this can lead to vague
testicular discomfort or a varicocele.
Most cases occur after repair of large indirect
hernias and are related to the extent of surgical
trauma in dissection of the hernial sac.
Avoid laparoscopy in patients with hx of
previous abdominal surgery
Avoid laparoscopic approach in irreducible
hernias if not adequately experienced
Urinary bladder injury does not cause
significant morbidity if immediately corrected
with primary suture in association with
decompression with a Foley catheter.
Urinary retention is seen in approximately 2%
Preoperative placement of a catheter may
actually increase the incidence of retention and
is avoided unless one feels that the bladder has
not been emptied preoperatively or that the
length of the procedure may be extended
Ask the patient to void before getting on the
If retention occurs post op, it can usually be
managed on an outpatient basis. Catheterize
and give adequate analgesia
A temporary insertion of a urinary catheter
which is usually removed after one to three
days. All patients eventually regain their
baseline control of initiating a urinary stream.
Inguinal and scrotal seromas: Some may mistake
it for a recurrent hernia.
Scrotal ecchymosis and inguinal hematoma due
to small vessel injuries
Testicular edema normally occurs when the
closure of the internal inguinal ring is excessively
tight around the spermatic cord.
Hydrocele= represents a persistence of the
vaginalis process, which loses its drainage into the
peritoneal cavity when the indirect sac is
disconnected. Most cases are resolved with a single
Scrotal elastic support for 3-4 weeks
Restricted physical activity.
Anti-inflammatory medication may be used.
If left alone, the seroma spontaneously resolves
in 90% patients.
If, however, the seroma is large or
symptomatic, a single aspiration usually
eliminates the problem.
The rate of infection in the skin orifice is less
than 1%, according to several studies.
Treatment is simple, consisting of drainage and
dressings. Antibiotics are used only when there
are systemic repercussions
Less frequent in endoscopic hernia repair than
in open repairs, with a rate of about 8%
Small-bowel obstruction after a laparoscopic
hernia repair can occur. It is the result of
adhesions to inadequately covered mesh or
due to intestines being entrapped in a defect
left in the peritoneum.
can be avoided by suturing the peritoneal
defect instead of tacking it.
constipation is common with the use of
narcotic pain medication, and can be managed
with a stool softener or laxatives.
The groin discomfort may be secondary to the
gas used during surgery and the dissection
rarely the mesh material or tacks (if used) can
cause chronic pain
There are a variety of mesh fixation materials
that surgeons may choose to use, and all have a
rare, but possible association with causing
groin pain. These fixation options include
(staples, permanent tacks, absorbable tacks, or
glues). Some surgeons do repair without using
mesh fixation materials at all.
If pain persists despite conservative measures
and the pain is isolated to a specific point on
the abdominal wall or the distribution of a
specific nerve, exploration is warranted. the
surgeon should explore the posterior wall
laparoscopically, looking for the offending
staple to remove it
It is extremely rare for mesh to become primarily
infected if it is completely extra peritoneal.
isolated incidences of extra peritoneal mesh
secondary infection due to a ruptured appendix or
perforated diverticulum of the colon.
In these cases, the patient can present with an
indolent chronic infection years after the repair
that is difficult to eradicate without removing the
mesh thus Mesh infections should be treated with
A biologic mesh may be substituted for the
original mesh if the resulting defect is a concern.
Cases in which the mesh has eroded into the
bladder have also been seen (purulent
Even rare cases of mesh migrating into scrotum
have been reported
Spiral tacks have also been reported to erode
into adjacent viscera.
Result from inadequate surgical technique.
The inadequate fixation of Marlex mesh,
Inadequate size of the mesh (small)
and a flaw in covering unidentified hernial defects
(hernias which had never been repaired) are the
main reasons for early recurrence of hernia.
Use of incised mesh
Inadequate dissection and missed cord lipoma
Displacement of mesh
The causes of late recurrence of hernia could be
stress on the tissues and the intrinsic weakness of
A new complication after inguinal hernia
repair, the late development of a trocar hernia
has been seen after the TAPP approach.
They may be Richter hernias or typical
They usually occur in ports that are ≥10mm in
size but have been reported in 5-mm ports