Rare Intraoperative and Postoperative Complications After Transabdominal Laparoscopic Hernia Repair: Results from the Multicenter Wall Hernia Group Registry

Abstract

Background:

Inguinal hernioplasty is the most frequently performed operation in the Western world today. Although the laparoscopic approach for inguinal hernia repair has shown excellent results in terms of complications and recurrences, the anterior approach is still the most used. Postoperative pain and recurrences are the most widely studied complications in both approaches, but there is little information about the often more troublesome rare complications of laparoscopic surgery and their treatment.

Methods:

In the period from January 1, 2014 to December 31, 2019, 1874 hernioplasty operations were performed with the transabdominal approach and recorded prospectively in the Wall Hernia Group database. The mean follow-up was 47 months (range 3–64 months). All less frequent complications were analyzed and a literature review was carried out to assess the presence of similar cases and their treatment in other series.

Results:

Eight cases of rare complications were identified and subdivided according to the Clavien-Dindo classification. They included a bowel perforation, 4 cases of bleeding, 2 bowel obstructions, and an injury to the motor branch of the obturator nerve. The postoperative course in these patients was significantly longer than in patients with a regular postoperative course. In 2 cases the complication occurred during the first admission, while the remaining 6 patients had to be readmitted within 30 days after discharge.

Conclusions:

Although serious postoperative complications in laparoscopic inguinal hernioplasty are rare, all surgeons, also those who have completed the learning curve, should be aware of their possible occurrence.

Introduction

Inguinal hernioplasty is the most widely performed operation worldwide, with a total of about 20 million operations each year. In fact, the chances of developing an inguinal hernia in a lifetime are 27%–43% for men and 3%–6% for women.^1,2 Many surgical techniques for inguinal hernia repair have been described over the years, mostly designed to reduce recurrences and postoperative pain.

The first real revolution in abdominal wall surgery was the introduction of prosthetic meshes for hernia repair, leading to a significant reduction of recurrences. Many new and innovative mesh materials have been used since then to reduce inflammatory reactions and allow optimal fixation. This resulted in a progressive shift to the tension-free technique described by Lichtenstein.³

The second revolution was the advent of minimally invasive techniques. Thirty years have passed since the description of the first laparoscopic inguinal hernioplasty and, although the widespread use of the technique was initially hampered by technical difficulties, today the laparoscopic approach is universally considered safe and effective.^4,5

The laparoendoscopic technique was initially proposed only for the treatment of recurrent and bilateral hernias, but, as shown by the recent guidelines of the Hernia Surge Group, it is safe and effective also in unilateral hernias as long as the operation is carried out by an experienced surgeon.¹

The literature clearly demonstrates that the results of transabdominal preperitoneal patch plasty (TAPP) and total extraperitoneal patch plasty (TEP) are superimposable in terms of recurrences, complications, and mortality, also compared with the anterior approach, but some intra- and postoperative complications may occur with the laparoendoscopic approach that are more serious and worrisome.^1,6,7 An indication of the severity of possible complications during TAPP and TEP is, for example, the so-called triangle of doom, the anatomical space containing the external iliac vessels.

Here we present a retrospective analysis from a prospective database of the less frequent complications of TAPP and their treatment as recorded in the multicenter Wall Hernia Group registry, with a review of the literature for each type of complication.

Materials and Methods

From January 1, 2014 to December 31, 2019, in the centers that are members of Wall Hernia Group, 1874 elective TAPP procedures were performed for inguinal, femoral, and obturator hernias. All cases were registered in the prospective database with an average follow-up of 47 months (range 3–64 months). Patients were followed up at 1 and 2 weeks, and at 1, 6, 12, and then every 6 months. One hundred seventy-six patients (9.5%) were lost to follow-up, leaving 1698 (90.5%) patients for evaluation. Intraoperative and postoperative complications were analyzed using the Clavien-Dindo classification.⁸ All procedures were performed by experienced surgeons who had completed the learning curve, defined as the performance of 65 laparoscopic hernioplasties.⁹ All patients received antibiotic prophylaxis consisting of a single dose of cephalosporin; anticoagulant therapy was provided in accordance with the Caprini score.¹⁰ Patients with ASA IV, those aged under 18, pregnant women, and patients with closed-angle glaucoma were excluded from surgery. All procedures were carried out under general anesthesia; a bladder catheter and nasogastric tube were placed only in selected patients and removed at the end of surgery. The European Hernia Society classification was used to subdivide the hernia types.¹¹ We additionally carried out a literature analysis for each type of complication to compare the presence of similar complications and their treatment in the literature with our own results. Using the Boolean operators AND/OR, 2 researchers independently searched the main archives PubMed, Scopus, Google Scholar, and the Cochrane databases. Only articles written in English were included in the analysis.

Results

During the study period 408 (22.5%) hernioplasties were performed for unilateral hernias and 1466 (77.5%) for bilateral hernias. The characteristics of the patients are summarized in Table 1. There were 1549 (80%) primary hernias, 290 (15.5%) hernias with a single recurrence, and 8 (0.5%) with multiple recurrences. The series included 1049 (56%) medial hernias, 788 (42%) lateral hernias, and 37 (2%) scrotal hernias. The mean operative time was 45 minutes (range 32–80 minutes) and the mean total postoperative hospital stay was 1.3 days (range 1–24). Conversion to open surgery was necessary in 2 cases (0.1%). Mortality at 30 days was 0%. Complications were summarized in Table 2. The standard size of all meshes was 15 × 12 cm. In 850 (45%) patients lightweight, partially absorbable or permanent (Ultrapro by Johnson&Johnson and Parietex by Medtronic), meshes were not fixed and 5 mL fibrin glue per side were used as an adjunct to hemostasis and facilitate adhesion formation, while self-adhesive meshes (Progrip by Medtorinic) were used in 1024 (55%) patients. Rare and/or severe complications occurred in 8 cases (0.5%), which are summarized in Table 3. In these patients the mean hospital stay, excluding readmission, was 5.5 days (range 1–8 days). All complications occurred during bilateral hernioplasties, four of which for monolateral recurrent hernias. Five patients (62%) had direct inguinal hernias, two (25%) had external oblique hernias, and one (13%) an obturator hernia. In 1 case (13%), the complication was detected and treated intraoperatively with conversion to laparotomy; in another (13%), it was detected while the patient was still in hospital and treated the following day. In the remaining 6 (74%) cases it was detected and treated during a second admission. The diagnosis of complications was made within 10 days after discharge (range 3–10 days). The average hospital stay of patients who were admitted a second time was 9.8 days (range 5–24 days). One of the 4 patients with vascular complications was found to have a factor VIII abnormality but the bleeding was caused by an epigastric artery injury; in the other 3 cases the source of the bleeding was not identified.

Table 1.

Patient Characteristics

Age (years)	52.7 (range 21–81)
Sex (n)	Female 413 (22%)
Sex (n)	Male 1461 (78%)
Body mass index	28.5 (range 20–32.5)

Table 2.

Complications

Seroma, n (%)	24 (1.2)
Hematoma, n (%)	27 (1.4)
Chronic pain, n (%)	3 (0.2)
Recurrences, n (%)	12 (0.5)
Missed Lipoma syndrome, n (%)	3 (0.2)

Table 3.

Rare Complications and Treatment

Patient	Gender; age	Complication	Clavien-Dindo	Treatment	Readmission
1	M; 38	Bowel perforation	IIIb	Intraoperative suture of the laceration with anterior hernioplasty	No
2	M; 76	Bowel obstruction	IIIb	Reoperation with adhesiolysis and reopening of peritoneal flap after 5 days	Yes
3	M; 65	Bowel obstruction	IIIb	Reoperation with adhesiolysis after 3 days	Yes
4	F; 72	Obturator nerve injury	I	Conservative treatment: physiotherapy and medication	No
5	M; 68	Retroperitoneal hematoma	II	Conservative treatment: blood transfusion	Yes
6	M; 65	Bleeding	IIIb	Reoperation with hemostasis and blood transfusion after 3 days	Yes
7	M; 53	Bleeding	IIIb	Reoperation with hemostasis and blood transfusion after 3 days	Yes
8	M; 65	Bleeding	II	Conservative treatment: blood transfusion	Yes

Discussion

Laparoendoscopic hernioplasty exposes the patient to potentially much more serious complications than those deriving from open surgery, although the guidelines published by the Hernia Surge Group have shown that the rate of visceral and vascular lesions in laparoendoscopic hernia surgery is very low.¹ In fact, visceral injuries after TAPP have been reported in 0.3%–0.6% of cases versus 0.2%–0.1% in TEP, while vascular injuries are slightly more frequent with TEP (0.4%) than TAPP (0.1%–0.2%).^1,12–14 Despite the limited incidence, these complications are worrying as they can worsen the postoperative course and sometimes even have a fatal outcome. The mortality following hernioplasty surgery is very low, 0%–2%, and tends to be mostly related to emergency surgery and the presence of comorbidities.¹ In the published series the types of postoperative complications and their treatment are not always detailed, which makes the analysis of the literature dealing exclusively with major complications difficult and incomplete.^12,13

Hernioplasty-related visceral injuries can be subdivided according to the time of their detection, that is, intraoperative or postoperative; in laparoscopic surgery they may involve the bowel or bladder. The damage may be caused either directly by the surgical instruments or indirectly by the materials used for hernia repair.

Injuries to the bladder generally occur during repair of incarcerated scrotal hernias.^14,15 Although the routine placement of a bladder catheter is controversial, we recommend it in patients with scrotal hernias, patients with suspected extensive adhesions that could markedly prolong the procedure, and patients with multiple recurrences.¹⁵

In the literature the reported incidence of intestinal damage during TAPP surgery is 0.09%, which is in line with our present findings.^1,6,11,12 A visceral injury detected intraoperatively must be corrected immediately; many surgeons would choose to defer mesh placement although some evidence suggests that this may be acceptable.^16,17 Intestinal damage during the postoperative course should be suspected in the event of fever, nausea and vomiting, and abdominal pain, possibly with a peritoneal reaction. The diagnosis should be substantiated by X-ray and CT of the abdomen to detect the presence of fluid and free air.

Unlike injuries to the bladder, intestinal injuries can be caused during trocar insertion, and although the incidence of visceral damage caused by trocars or Veress needles is very low even in general surgery, it should not be underestimated as it may result in increased length of stay, reoperation, and even death.^17,18 The recent Cochrane review comparing trocar insertion techniques has shown a lack of evidence to indicate what is the best technique to reduce the incidence of visceral injuries.¹⁷

Visceral lesions can be caused by electrosurgical and cold instruments; they may occur during adhesiolysis, by accidental direct contact or during the reduction of hernia sac contents, especially in scrotal hernias.^16,19–21 The Trendelenburg position can be helpful to distance the bowel from the inguinal region, thereby reducing the risk of contact with coagulation instruments.²² We recommend protecting the bowel with gauze if it is tightly adherent to the parietal peritoneum of the inguinal region and to always insert instruments under direct vision. Adhesiolysis of adhesions between the bowel and the abdominal wall should be performed with cold scissors, sacrificing, if needed, parts of the peritoneum to preserve the bowel.^21,23 However, as mentioned by Di Saverio et al., laparoscopic adhesiolysis is not always easy to perform and requires technical expertise to reduce the risks associated with the procedure.²¹ In our experience, if it proves impossible to reach the inguinal region safely, conversion to open surgery to avoid greater damage is the best option.

The wide preperitoneal dissection during TAPP allows placement of a mesh of adequate size. However, it exposes the vascular structures in the inguinal region encompassing the triangle of doom or the vascular network referred to as corona mortis, making them prone to injury.²⁴ Injury to vascular structures is a possible source of postoperative bleeding in laparoscopic hernioplasties. The literature shows that the incidence of vascular injuries is higher in patients undergoing TEP than in those undergoing TAPP, although the reoperation rates with the two techniques overlap.^1,6,12

The presence of comorbidities and the size of the hernia defect are factors correlating with the postoperative complications that most frequently necessitate reoperation.^1,6 The use of antithrombotics and anticoagulants in patients who are candidates for inguinal hernioplasty by the anterior approach leads to a higher risk of bleeding than when a laparoscopic approach is used.²⁵ As in all surgery, also liver cirrhosis and coagulopathy predispose the patient to an increased bleeding risk.^1,24,26 Data from the German Herniamed registry showed that patients undergoing open surgery more often needed reoperation, although they also were the ones with the highest risk of preoperative bleeding.¹ Bracale et al. observed that the treatment of postoperative bleeding in patients undergoing laparoscopic hernioplasty was often underreported.¹²

In our experience the use of procoagulants, including some of the fibrin glues that are also used for fixation of the mesh, can prevent and control the small bleeds that may occur during dissection.⁴ However, postoperative bleeding can lead to the formation of a hematoma that, if extensive, may require interventional treatment up to several months after surgery. The incidence of postoperative hematomas after TAPP is 3.4%, and Chmatal and Keil reported successful surgical treatment by the anterior approach of two pseudotumoral masses that appeared after TAPP surgery and persisted over time.^27,28

Bleeding after TAPP may also be caused by accidental injury to the epigastric artery; while this is easy to treat intraoperatively by closing the artery with clips, late bleeding due to the collection of blood in the preperitoneal space makes selective ligation of the artery difficult and requires surgical intervention with the Stoppa technique. The literature reports a 0.3%–2.5% incidence of epigastric artery injury caused mostly by pelvic trauma, although cases of iatrogenic damage during cesarean sections, needle biopsies, and drain placement have also been described.^29,30 This complication can be treated by embolization, but from our literature study it appears there have been no cases of endovascular treatment for epigastric artery bleeding after TAPP.³⁰

Although Köckerling et al. reported that the laparoscopic approach is associated with less bleeding than the open technique in patients with coagulopathies, their article provides no information about its treatment or the postoperative course of these patients.²⁶ In our experience, vascular complications after laparoscopic hernioplasty, although rare, can be extremely worrying; they can be managed using endovascular treatment, if available, or surgery, although the latter requires considerable technical skill given the delicate anatomical space one has to work in.

The incidence of obstruction after TAPP is very low; only sporadic cases of postoperative bowel obstruction have been reported. Possible causes include herniation at the trocar insertion site, intestinal adhesions, and incarceration through the previous hernia defect.^1,6,12,13,31 In surgical practice bowel obstruction is one of the most frequent causes of emergency surgery, with considerable treatment-related costs and outcomes that are not always satisfactory.^23,32 In our opinion the real incidence of postoperative bowel obstruction after TAPP is probably underestimated: results may be confounded by patients having undergone other procedures and the obstruction not having been attributed to TAPP but to another cause.

Compared with the endoscopic approach, laparoscopic hernia repair requires opening of the peritoneum, with the creation of a flap for the placement of the mesh and closure of the peritoneum at the end of the procedure. Various methods to close the peritoneum were proposed and different devices were used in the past, which were later abandoned also because they caused postoperative adhesions.^33,34 The introduction of self-anchoring barbed sutures, initially proposed for gynecologic and urologic surgery, has simplified and shortened the procedure of peritoneal closure in TAPP.³⁵ However, Buchs and colleagues described a case of intestinal obstruction caused by a barbed suture device, and 3 subsequent cases of obstruction after TAPP surgery were reported in the literature.^33,36–38 All 3 patients underwent reoperation with different timings and diagnostic criteria, and it is likely that the decision algorithm proposed by the Adhesive Small Bowel Obstruction (ASBO) Working Group will prove helpful in similar cases.²³ We agree with the observations of Köhler et al. about the precautions to be taken in peritoneum closure: although it is one of the final steps of a laparoscopic hernioplasty, it must be performed with the same attention as the rest of the surgery to avoid undesirable and unforeseen events.³³

The prevention of chronic pain in inguinal hernias has always been an important concern for surgeons. Its incidence varies from 10% to 22% in open surgery, while in laparoscopic surgery it is only 1%.^1,6,13,31 The incidence of this complication, which is likely to be underestimated, and the significant discomfort associated with it make chronic pain one of the most dreaded surgical complications after hernioplasty. Age under 65 years and severe postoperative pain are predictive factors for the onset of chronic pain; conversely, Campanelli and colleagues observed that proper identification and preservation of the nerve structures during open hernioplasty reduce the incidence of chronic pain.^1,39,40

The standardization of surgical techniques and the introduction of new materials for the laparoscopic treatment of inguinal hernias have contributed to pain prevention. Nerve injuries occurring during laparoscopic hernioplasty mostly involve the genitofemoral and femoral cutaneous nerves.⁴¹ Only 1 case of obturator nerve injury after laparoscopic hernioplasty has been described previously.⁴² Iatrogenic injury to the obturator nerve is most common during gynecologic surgery, but has also been reported during aortofemoral bypass surgery, radical prostatectomy, and hip replacement surgery.⁴³ The obturator nerve originates from the nerve roots of L2–L4 and divides into an anterior and a posterior branch; in 13%–40% of cases there is an accessory nerve originating from L3 to L4.⁴⁴

Nerve injuries during TAPP tend to be caused by mesh fasteners, particularly in the triangle of pain or, as described by Haminec et al., in the proximity of the obturator foramen. In our own experience, the injury to the motor branch of the obturator nerve was caused by thermal damage during hemostasis of a vascular injury.⁴² The diagnosis of obturator nerve injury is based on neurologic assessment and electromyography.⁴⁵ In our case the nerve damage inhibited adduction of the thigh but was not associated with pain; we therefore treated it conservatively, prescribing vitamin supplements and rest.^42,45 In fact, unlike the Howship-Romberg sign (painful adduction, extension, and medial rotation), which can be managed both medically and surgically, walking difficulty does not call for surgical treatment.⁴² Based also on the findings of Haminec et al., we believe that, although injury to the obturator nerve is rare, preventing it is advisable; this can be done by avoiding mesh fixation at the level of the obturator foramen and, in the case of bleeding, using bipolar forceps or preferably a hemostatic solution for hemostasis.⁴²

In conclusion, severe postoperative complications after laparoscopic hernioplasty are rare but may have a major impact on the postoperative course of this benign condition. It is important to take into account also the medical–legal aspects and to warn the patient about these possible events that can drastically change the postoperative course. Finally, in our opinion laparoscopic hernioplasty, even when performed by an experienced surgeon, requires greater technical skill than many of the laparoscopic operations that are commonly considered as major surgery. Also the fact that it is almost always an elective operation performed for a benign condition means that it requires our special attention.

Availability of Data and Materials

The data supporting the conclusions of this article are included within the article. Data are available from the corresponding author upon reasonable request.

Consent for Publication

This retrospective study was approved by the Ethics Board of Treviso and was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all individuals included in the study.

Footnotes

Authors' Contributions

A.S. was the lead author and conceived the study. M.D.L. contributed to data analysis and writing the article. All authors reviewed the article. All authors approved the final version of the article.

Funding Information

No funding was received for this article.

References

The Hernia Surge Group International guidelines for groin hernia management. Hernia, 2018; 22:1–165.

Kingsnoth

, LeBlanc

. Hernias: Inguinal and incisional. Lancet, 2003; 362:1561–1571.

Amato

, Moja

, Panico

, et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev, 2012; CD001543.

Sartori

, De Luca

, Clemente

, et al. Is human fibrin sealant a possible choice for the fixation of laparoscopic inguinal hernia repair? A single center experience and the analysis of the results after 326 TAPP in two years. G Chir, 2018; 34:309–314.

Ger

, Monroe

, Duvivier

, Mishrick

. Management of indirect inguinal hernias by laparoscopic laparoscopic closure of the neck of the sac. Am J Surg, 1990; 159:370–373.

Kockerling

, Bittner

, Jacob

, Seidelmann

, et al. TEP versus TAPP: Comparison of the post-operative outcome in 17,587 patients with a primary unilateral inguinal hernia. Surg Endosc, 2015; 29:3750–3760.

Lovisetto

, Zonta

, Rota

. Laparoscopic transabdominal preperitoneal (TAPP) hernia repair: Surgical phases and complications. Surg Endosc, 2007; 21:646–652.

Dindo

, Demartines

, Clavien

. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of survey. Ann Surg, 2005; 240:205–213.

Bracale

, Merola

, Sciuto

, et al. Achieving the learning curve in laparoscopic inguinal hernia repair by Tapp: A Quality Improvement Study. J Invest Surg, 2019; 32:738–745.

10.

Caprini

JA.

Risk assessment as guide for the prevention of the many faces of venous thromboembolism. Am J Surg, 2010; 199,(1 Suppl):S3–S10.

11.

Simons

, Aufenacker

, Bay-Nielsen

, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia, 2009; 13:343–403.

12.

Bracale

, Melillo

, Pignata

, et al. Which is the best laparoscopic approach for inguinal hernia repair: TEP or TAPP? A systematic review of the literature with network meta-analysis. Surg Endosc, 2012; 26:3355–3366.

13.

Aiolfi

, Cavalli

, Michieletto

, et al. Primary inguinal hernia repair: Systematic review and Bayesian network meta-analysis comparing, open, laparoscopic transabdominal preperitoneal, totally extraperitoneal and robotic preperitoneal repair. Hernia, 2019; 23:473–484.

14.

Siow

, Mahendra

, Hardin

, Chea

, Nik Azim

. Laparoscopic transabdominal approach and its modified technique for incarcerated scrotal hernias. Asian J Surg, 2013; 36:64–68.

15.

Francois

, Defoort

, Muysoms

. Complicated inguino-scrotal bladder hernia: A case of two-step repair. Acta Chir Belg, 2017; 117:122–124.

16.

Birindelli

, Sartelli

, Di Saverio

, Coccolini

, et al. Update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg, 2017; 12:37.

17.

Ahmad

, Baker

, Finnerty

, Philips

, Watson

. Laparoscopic entry techniques. Cochrane Database Syst Rev, 2019; 2019.

18.

Schafer

, Lauper

, Krahenbuhl

. Trocar and Veress needle injuries during laparoscopy. Surg Endosc, 2001; 15:275–280.

19.

Schrenk

, Woiserschlager

, Rieger

, Wayand

. Mechanism, management and prevention laparoscopic bowel injuries. Gastrointest Endosc, 1996; 43:572–574.

20.

Eisner

, Wadhwa

, Downing

, Singhal

. Prevention and management of bowel injury during gynecologic laparoscopy: An update. Curr opin Gynecol, 2019; 31:245–250.

21.

Di Saverio

, Birindelli

, broek

, Davies

, Mandrioli

, Sallinen

. Laparoscopic adhesiolysis: Not for all patients, not for all surgeons, not in all centers. Updates Surg, 2018; 70:557–561.

22.

Bittner

, Schwarz

. Inguinal hernia repair: Current surgical techniques. Langerbecks Arch Surg, 2012; 397:271–282.

23.

ten Broek

R P.G.

, Krielen

, Di Saverio

, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working-group. World J. Emerg Surg, 2018; 13:24.

24.

Noussios

, Galanis

, Chatzis

, Kostantinidis

, Filo

, Karavasilis

, Katsourakis

. The anatomical characteristics of Corona Mortis: A systematic review of the literature and its clinical importance in hernia repair. J Clin Med Res, 2020; 12:108–114.

25.

Staerkle

, Hoffmann

, Kockerling

, Adolf

, Bittner

, Kirchhoff

. Does coagulopathy, anticoagulant or antithrombotic therapy matter in incisional hernia repair? Data from Herniamed Registry. Surg Endosc, 2018; 32:3881–3889.

26.

Köckerling

, Roessing

, Adolf

, Schug-Pass

, Jacob

. Has endoscopic (TEP, TAPP) or open inguinal hernia repair a higher risk of bleeding in patients with coagulopathy or antithrombotic therapy? Data from the Herniamed Registry. Surg Endosc, 2016; 30:2073–2081.

27.

Chmatal

, Keil

. Inguinal tumorous mass—An uncommon late manifestation of chronic organized hematoma after laparoscopic transabdominal preperitoneal inguinal hernia repair: Two case reports. Int J Surg Case Rep, 2020; 66:215–217.

28.

, Way

, Eslick

, Cox

. Transabdominal pre-peritoneal versus open repair for primary unilateral inguinal hernia: A meta-analysis. World J Surg, 2018; 43:1304–1311.

29.

Joy

, Prithishkumar

, Isaac

. Clinical anatomy of the inferior epigastric artery with relevance to invasive procedures of the anterior abdominal wall. Minim Access Surg, 2017; 13:18–21.

30.

Wong

, Merkur

. Inferior epigastric artery: Surface anatomy, prevention and management of injury. Aus N J Obstet Gynaecol, 2016; 56:137–141.

31.

Bittner

, Arregui

, Bisgaard

, Dudai

, Ferzli

, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc, 2011; 25:2773–2843.

32.

Scott

, Olufajo

, Brat

, Rose

, Zogg

, et al. Use of national burden to define operative emergency general surgery. JAMA Surg, 2016; 151:e160480.

33.

Köhler

, Mayer

, Lechner

, Bittner

. Small bowel obstruction after TAPP repair cause by self-anchoring barbered suture device for peritoneal closure: Case report and review of literature. Hernia, 2015; 19:389–394.

34.

Luijendijk

, de Lange

, Wauters

, Hop

, et al. Foreign material in postoperative adhesions. Ann Surg, 1996; 223:242–248.

35.

Takayama

, Nakai

, Shiozaki

, Ogawa

, Sakamoto

, Takeyama

. Use of barbed suture of peritoneal closure in transabdominal preperitoneal hernia repair. World J Gastrointest Surg, 2012; 4:177–179.

36.

Buchs

, Ostermann

, Hauser

, Roche

, Iselin

, Morel

. Intestinal obstruction following use of laparoscopic barbered suture: A new complication with new material?. Min Inv Ther, 2012; 21:369–371.

37.

Filser

, Reibetanz

, Krajinovic

, Germer CT Dietz

, Seyfried

. Small bowel volvulus after transabdominal preperitoneal hernia repair due to improper use of V-Loc™ barbed adsorbable wire—Do always “read instruction first”?. Int J Surg Case Rep, 2015; 8C:193–195.

38.

Sartori

, De Luca

, Clemente

, De Luca

, Scaffidi

, Piatto

, Noaro

, Campagnaro

. Small bowel occlusion after trans-abdominal preperitoneal hernia approach caused by barbed suture: Case report and review of literature. G Chir, 2019; 40:322–324.

39.

Charalambous

, Charalambous

. Incidence of chronic groin pain following open mesh inguinal hernia repair, and effect of elective division of the ileoinguinal nerve: Meta-analysis of randomized controlled trials. Hernia, 2018; 22:401–409.

40.

Alfieri

, Amid

, Campanelli

, Izard

, Kehlet

, Wijsmuller

, Di Miceli

, Doglietto

. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia, 2011; 15:239–249.

41.

Birk

, Hess

, Garcia-Pardo

. Low recurrence rate and low chronic pain associated with inguinal hernia repair by laparoscopic placement of Parietex Progrip™ mesh; clinical outcomes of 220 hernia with mean follow-up at 23 months. Hernia, 2013; 17:313–320.

42.

Kitagawa

, Kim

, Reid

, et al. Surgical management of obturator nerve lesions. Neurosurgery, 2009; 65,(Suppl 4):A24–A28.

43.

Haminec

, Horak

, Kaiser

. Obturator nerve injury in laparoscopic inguinal hernia mesh repair. Hernia, 2013; 17:801–804.

44.

Vasilev

SA.

Obturator nerve injury: A review of management options. Gynecol Oncol, 1994; 53:152–155.

45.

Rafii

, Quereleu

. Laparoscopic obturator nerve neurolysis after pelvic lym, phadenectomy. J Min Inv Gynecol, 2006; 13:17–19.