Since its introduction in 1991, laparoscopic inguinal hernia repair has become more and more widely used in clinical practice, but some complications have arisen as well. In this paper, we discuss the causes, prevention and management of various complications of LIHR, combining literature reports and our own experience. Intraoperative complications Transepithelial anterior peritoneal repair (TAPP) and total extraperitoneal repair (TEP) are the two gold standard procedures for LIHR. The anatomical characteristics of the interstitial space under the lumpectomy view are the key to prevent intraoperative complications. 1. Vascular injury 1. Injury to the inferior abdominal wall artery: The external iliac artery divides into the inferior abdominal wall artery before passing below the iliac pubic bundle and becoming the femoral artery, and then goes up along the outer edge of the rectus abdominis muscle and coincides with the superior abdominal wall artery. The inferior abdominal wall artery is pulsatile, very easy to identify, and is an important marker for access to the anterior peritoneal space. care should be taken not to injure the inferior abdominal wall artery during TAPP when incising the peritoneum; TEP may cause suspension or injury to the inferior abdominal wall artery if the level separation is too shallow when establishing the anterior peritoneal space. Electrocoagulation for hemostasis is ineffective in the case of inferior abdominal wall artery injury, and hemostasis with titanium clips may be the only solution. Injury to the crown of death (ring of death): About 3/4 of patients have an anastomotic branch between the inferior abdominal wall artery and the foramen ovale artery. Sometimes this anastomotic branch is abnormally large and is called the “anomalous foramen ovale branch” because both ends are connected to the artery. It causes large hematoma in the scrotum after surgery, and even death has been reported, so it is called “Corona Mortis”, because it passes through the femoral vein medially, behind the pubic comb ligament in a circular pattern, also called “Circle of Death”. (Circle of Death). The literature reports that the “crown of death” can be seen in about 14% of patients. Most “crown of death” injuries occur when the patch is fixed to the pubic commissure ligament and can be stopped by electrocoagulation. 3. External iliac vessel injury: The external iliac artery is located in the triangular gap enclosed by the vas deferens and the spermatic vessels, which is a dangerous area and can cause fatal bleeding after injury. Back in the early days of LIHR in 1991, it was named the “Doom Triangle” and all surgeons are highly cautious of this area, so these complications are rarely reported now. 4, spermatic vessels / uterine garden ligament injury: spermatic vessels and vas deferens are separate before entering the inguinal canal, the former is located laterally, the latter is located medially, the two converge at the level of the inner ring mouth into a structure both spermatic cord, into the inguinal canal, the right spermatic vessels and vas deferens form a slightly smaller angle than the left. In patients with a long history of disease, sometimes the hernia sac is densely adherent to the spermatic vessels and the preperitoneal fat, which can damage the spermatic vessels or their branches when stripped. Injury to the spermatic vessels can be stopped by electrocoagulation or titanium clips, but not by clamping or cutting the spermatic vessels if possible, otherwise the blood supply to the testes will be affected. In female patients, the adhesions between the round ligament of the uterus and the peritoneum are very dense, and it is more difficult to completely separate the two. Unlike male patients, female patients do not emphasize the “abdominal walling” of the uterine garden ligament, so a patch can be cut and laid flat behind the uterine garden ligament to reduce the chance of injury to the uterine garden ligament; the uterine garden ligament can also be cut, but it will cause prolapse of the uterus. 5, posterior pubic plexus injury: the posterior pubic plexus is located in the deep surface below the pubic tuberosity and pubic branch, which converges into the dorsal penile plexus in the direction of perineum, sometimes very thick, and it is not easy to stop bleeding after injury. The posterior pubic plexus is not damaged when separating the pubic bladder space (Reztius space) as long as it is not deeper than the longitudinal surface of the pubic symphysis. Once injured, only pressure can be applied to stop the bleeding. There is a unique anatomical area “pain triangle” in the lumpectomy, which is crossed by the lateral femoral cutaneous nerve and the femoral branch of the genitofemoral nerve, on the lateral side of the spermatic vessels and below the iliopubic bundle. The lateral femoral cutaneous nerve is located on the anterolateral aspect of the thigh and provides innervation of the lateral thigh skin sensation, causing abnormal sensation of the lateral thigh nerve after injury. The femoral branch of the genitofemoral nerve enters the femoral sheath and innervates the sensation of the skin of the proximal anterior thigh, causing sensory hypersensitivity in the femoral triangle after injury. When separating the anterior peritoneal space, excessive separation should not be done in the “pain triangle”, and stapling the patch in this area is strictly prohibited. The surface of the “pain triangle” often has a thin layer of preperitoneal fatty tissue, protecting this layer of tissue will not injure the nerve. The vas deferens, like the spermatic vessels, is covered by the peritoneum (hernia sac) in front of it. In patients with a long history of disease, the vas deferens adheres closely to the preperitoneal fat and the peritoneum, causing injury when the hernia sac is removed. Currently, there is no way to repair vas deferens damage, so it is important to ensure that the vas deferens is not damaged in young patients, especially those who have not had children. IV. Some people think that TAPP is operated in the abdominal cavity, while TEP does not enter the abdominal cavity, so only TAPP can cause injury to the intestinal canal, which is wrong. In fact, it is the TAPP that enters the abdominal cavity and can clearly observe the abdominal cavity, so it will not damage the intestinal canal, while the TEP does not enter the abdominal cavity and cannot see the hernia contents, so it may damage the intestinal canal. The incidence of intestinal canal injury in TEP is reported in the literature to be about 0.15%. When the hernia contents are not completely retracted or slip hernia, there is a risk of injury to the intestinal canal when the hernia sac is clamped or transected. V. Bladder injury The incidence of bladder injury is very low. In TEP, when the anterior peritoneal space is successfully established, the bladder naturally enters the lower part of the visual field and is not easily damaged; in TAPP, if the peritoneum is incised on the medial side of the medial umbilical ligament, there is a risk of bladder injury. plasma membrane. In patients with a history of lower abdominal and especially prostate surgery, the pubic bladder space is densely adherent and forced separation can increase the chance of bladder injury. Postoperative complications The LIHR incision is located away from the patch repair area and few incisional complications have been reported. With the maturation of laparoscopic techniques, complications due to puncture and pneumoperitoneum reported earlier are also rare. Currently the most common postoperative complications are mainly seroma, temporary neurosensory abnormalities, urinary retention and chronic pain. There are also some rare but serious complications (complications that require reoperative intervention) that deserve attention. I. Seroma Seroma is the most common complication of LIHR, with an incidence of about 5%. A true hematoma (hematoma) appears within 24 hours after surgery and presents as a bruised mass in the groin area or scrotum. Branches of the spermatic vessels that were injured during intraoperative stripping of the hernia sac and regressed into the inguinal canal without timely detection, or branches of the occluding vessels that were injured during stapling of the patch, can cause significant hematoma postoperatively; the higher vascular fragility of older patients and traumatic oozing of blood is also a major cause of hematoma formation. Treatment such as external application of skin nitrate can be given, and the hematoma will gradually subside after 2-3 weeks. Most of the hematomas are thick and not easy to puncture, so do not force drainage except in special cases to avoid infection. Seroma, which appears within 1 week after surgery, is mild and contains plasma clarified fluid, mainly due to fluid secretion from the distal open hernia sac after transection of the hernia sac, and may also be caused by incomplete closure of the peritoneum and leakage of intra-abdominal fluid into the anterior peritoneal space. Theoretically, stripping the hernia sac as completely as possible will reduce the incidence of seroma, but the loss of hematoma due to forced stripping of a densely adherent hernia sac will be outweighed by the loss of hematoma. Smaller seromas may subside on their own after hot compresses and do not need to be treated, while larger ones may be punctured and healed after 1-2 punctures, with strict adherence to the principle of asepsis to avoid infection. The incidence of seroma is closely related to the hernia type, and the incidence of type III and IV hernia is significantly higher than that of type I and II hernia. The incidence of seroma is significantly higher in type III and IV hernias than in type I and II hernias. It has been reported in the literature that leaving a 24-hour closed drain can reduce the chance of seroma without increasing the risk of infection, but usually no drainage is placed in LIHR. Be careful not to mistake the seroma for a recurrence and perform unnecessary surgery. Nerve sensory abnormalities There are two types of nerve sensory abnormalities: transient and persistent, which may be related to nerve irritation by excessive separation, patching or herniation staples in the “pain triangle”. This complication was first reported by Eubanks in 1993. Persistent neurosensory abnormalities are true nerve injuries, mostly occurring when the hernia fixator is stapled to the patch, and present as persistent chronic neuralgia, which can be quite difficult to manage. Neurosensory abnormalities were more frequently reported in the early days. With the knowledge of anatomy (e.g., pain triangle), the development of material science (e.g., lightweight patches, non-invasive materials such as fibrin glue), and the updating of concepts (e.g., selective immobilization patches), such complications have become rare or even completely avoidable. Urinary retention Urinary retention is the main cause of prolonged hospitalization days and is definitely related to prostatic hyperplasia. The idea that the separation of the pubic bladder space and the coverage of the patch may induce urinary retention is not supported by the literature. In the author’s group, the incidence of urinary retention was 2.2% and all patients had a history of prostatic hyperplasia [16]. it is tentatively assumed that urinary retention is not a complication specific to LIHR. preoperative catheterization is not required for LIHR, and the inability to urinate on one’s own after surgery can be treated as general urinary retention. Chronic pain The incidence of chronic pain has been reported differently, ranging from 0.3% to 3%. There is no authoritative definition of the duration of chronic pain, but from most reports, pain lasting for more than 3 months can be called “chronic pain”. The use of fibrin glue instead of a hernia fixator to fix the patch significantly reduces the incidence of chronic pain, which would suggest a direct association with nerve injury, but chronic pain has been reported even in laparoscopic surgery without patch fixation, so there seems to be another reason for chronic pain. span=””>years), the incidence of chronic pain is somewhat higher. Chronic pain is poorly treated, and the principles proposed by Palumbo P et al. are informative: non-operative treatment is preferred, starting with oral analgesics, followed by local injections of anesthetics and prednisone when ineffective, with surgical treatment (e.g. removal of patches or nerve root resection) being the unavoidable last option. In contrast, Hussain A prefers aggressive surgical treatment, and in his group of 43 patients, 70% were cured and 20% improved after removal of the patch by laparoscopy, with impressive results. V. Infection of the abdominal cavity/inguinal region/ patch Intraoperative intestinal injury without detection is the main cause of postoperative abdominal infection. Once diagnosed, prompt surgery must be performed to clean and drain the abdominal cavity and remove the patch. It is important to remind that the peritoneum must be closed after removal of the patch, otherwise the lack of protection of the peritoneum when the intestinal canal enters the hernia defect area can cause intussusception or even strangulated intestinal obstruction. Most infections in the inguinal region are associated with secondary infection of the seroma, which should not be blindly and repeatedly punctured to reduce the chance of exogenous infection. Infection of the patch does not necessarily require immediate removal of the patch, but can be cured in most cases by attempting drainage or drug exchange. This method is controversial because leaving a puncture hole in the inguinal region increases the chance of patch infection. Mechanical intestinal obstruction There are three main reasons for mechanical intestinal obstruction: adhesions between the intestinal canal and the patch, adhesions between the intestinal canal and the hernia staple, and adhesions between the intestinal canal and the abdominal wall at the poke hole site. The consequences of intestinal obstruction caused by adhesions between the intestinal canal and the patch are the most serious, and even incomplete intestinal obstruction should be operated actively, because such adhesions are very dense and will eventually develop into complete intestinal obstruction or even intestinal fistula and intestinal necrosis. Theoretically, the patch is separated from the intestinal canal by the peritoneum in LIHR and no adhesions are produced, but such complications have been reported in both TAPP and TEP [23] due to incomplete closure of the peritoneum or a breach in the peritoneum. in TAPP, the peritoneum is closed as completely as possible, and such complications can be eliminated with continuous sutures; in TEP, although the peritoneum is not opened, intraoperatively, if the peritoneum is broken Although TEP does not open the peritoneum, it should also be closed as much as possible, and any doubts can be explored by entering the peritoneal cavity at the end of surgery. Intestinal obstruction due to adhesions of the intestinal canal to the hernia staple has also been reported; these adhesions are mostly banded and can be treated relatively simply by laparoscopic release of the band. Patients with inguinal hernia have a weak abdominal wall and high intra-abdominal pressure, and the incidence of poke hernia is higher than that of other laparoscopic procedures, and the poke hole must be closed at full level to avoid causing poke hernia. VII. Patch erosion Erosion of the patch into the adjacent organs is a distant complication that can occur years to decades after surgery. It is a rare but serious complication that is more difficult to manage. To date, only a dozen cases of patch erosion into the bladder have been reported. In addition, intraoperative injury to the bladder plasma membrane and curling of the patch back into place may also be factors. The erosion of the patch into the bladder can cause recurrent hematuria, urinary tract infection, and urinary fistula, and cystoscopy can clarify the diagnosis. Treatment includes measures such as excision of the sinus tract, removal of the patch, and resection of part of the bladder. Distant complications such as erosion of the patch into the small intestine, sigmoid colon and cecum have also been reported on a case by case basis, most notably due to incomplete closure of the peritoneum and adhesions between the intestinal canal and the patch. Such adhesions can cause mechanical manifestations of intestinal obstruction in the early stages and also erosion of the patch in the later stages, leading to complications such as intestinal fistula and intestinal necrosis. The preventive measures are the same as above, and the treatment principle is intestinal segment resection and removal of the patch. VIII. Acute ischemic orchitis Moore JB et al. reported a complication of acute ischemic orchitis in which severe pain and swelling of the testis occurred on the fourth postoperative day and ultrasound revealed no blood return signal in the testis, and the patient eventually underwent orchiectomy. This complication is different from ischemic orchitis caused after spermatic cord vascular ligation, which is an obstruction of arterial blood supply that may cause testicular atrophy and is a chronic process; the former may be caused by venous plexus embolism and is an acute process. It is necessary to recognize this complication when performing LIHR. LIHR is a rational and proven technique, and proper practice can minimize the rate of various complications, and various so-called “modifications” are not recommended between procedures that are not fully mastered and standardized in practice. In addition to laparoscopic technique, experience in hernia surgery and familiarity with the anatomy of the anterior hiatus are essential to prevent all types of complications.