What are the potential complications of open inguinal hernia repair?

Complications of Open Inguinal Hernia Repair

Open inguinal hernia repair carries an overall complication rate of 7-12%, with the most common complications being wound infections, bleeding, chronic pain, testicular complications, and hernia recurrence. 1, 2, 3

Common Perioperative Complications

Wound-Related Complications

• Surgical site infection occurs in approximately 0.5-1% of cases, with rates reaching 100% documentation in consent forms but actual clinical incidence remaining low 2, 3
• Bleeding/hematoma formation affects approximately 0.9% of patients and represents one of the most frequently documented complications 3
• Wound problems and scrotal swelling are among the most frequent early complications, occurring in the immediate postoperative period 1

Testicular and Reproductive Complications

• Testicular atrophy can occur due to injury to the testicular blood supply during dissection, though exact incidence varies 4, 5
• Vas deferens injury occurs in 1-8% of repairs, with higher rates in infants and preterm populations 4
• Impotence and fertility issues have been reported as long-term complications, particularly in bilateral repairs 5
• Hydrocele formation may develop postoperatively as a consequence of disrupted lymphatic drainage 5

Neurological Complications

• Chronic pain is a significantly underreported complication during consent, documented in only 14% of consent forms despite being a serious long-term morbidity 2
• Painful scars and neuromas can develop from nerve injury or entrapment during repair 5

Serious but Less Common Complications

Visceral Injuries

• Intestinal injury occurs in approximately 0.2% of cases and is poorly documented during consent (52.1% of cases) 2, 3
• Intestinal obstruction can occur as a late complication from adhesions or mesh-related issues 5
• Fecal and urinary fistulae represent rare but devastating complications requiring immediate surgical intervention 5

Cardiovascular and Pulmonary

• Pulmonary and cardiovascular complications occur in approximately 0.2% of repairs, with higher risk in elderly patients and those with elevated ASA scores 3

Hernia Recurrence

• Recurrence rates range from 1-10% for primary repairs and can reach as high as 35% for recurrent hernia repairs 1
• Mesh repair significantly reduces recurrence compared to tissue repair (OR = 0.2, P = 0.02), even in complicated cases 4
• Recurrence represents the most frequent long-term complication in some series (42% in resource-limited settings) 5

Risk Factors for Complications

Patient-Related Factors

• Advanced age (50-70 years) correlates with higher complication rates 3, 5
• Elevated ASA score significantly increases perioperative morbidity 3
• Diabetes mellitus increases infection risk and wound healing complications 3
• Active smoking impairs wound healing and increases complication rates 3

Surgery-Related Factors

• Emergency admission (versus elective surgery) substantially increases complication risk 3
• Bilateral hernias in males carry higher complication rates 3
• Surgery in low-resource settings shows dramatically higher complication rates due to technique and follow-up issues 3, 5

Clinical Severity of Complications

• Approximately 22% of complications are clinically significant (Clavien-Dindo grade ≥IIIa), requiring surgical, endoscopic, or radiological intervention 3
• 78% of complications are minor (Clavien-Dindo grade <III), requiring only medical management 3

Special Considerations in Pediatric Populations

• Postoperative apnea occurs in up to 49% of preterm infants, with risk inversely related to corrected gestational age 4
• Infants less than 46 weeks' corrected gestational age require at least 12 hours of postoperative monitoring 4
• Complication rates of 1-8% include recurrence, vas deferens injury, and testicular atrophy in the pediatric population 4

Critical Pitfalls to Avoid

• Inadequate informed consent is widespread, with serious complications like chronic pain (14%), testicular complications (45.3%), and visceral injury (52.1%) poorly documented, leaving surgical teams vulnerable to negligence claims 2
• Delayed repair of strangulated hernias dramatically increases morbidity and mortality, with delays beyond 24 hours associated with significantly higher mortality rates 6, 7
• Failure to identify bilateral hernias occurs in 11.2-50% of cases; laparoscopic approach allows visualization of the contralateral side 6, 8
• Poor surgical technique in resource-limited settings leads to preventable complications including stitch abscesses/sinuses (24.2%), testicular atrophy, and fistulae formation 5