Occurrence and management of postoperative bleeding in laparoscopic inguinal hernia repair: a single-institution case series

IntroductionOther Section

• Introduction
• Case presentation
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

The increased acceptance of inguinal hernia (IH) repair by a minimally invasive approach has led to numerous reports on technique, results, and complications related to this procedure. The procedure demonstrates the advantages of minimal invasiveness, such as rapid recovery and low recurrence rate. It has been recommended for adults with IHs in European guidelines (1). The addition of inguinal hernioplasty has led to the emergence of a new list of specific complications involving this procedure, many of which are directly related to surgical anatomy and technique. However, there is some concern regarding the possibility of bleeding after this procedure (2,3). Bleeding is a rare complication that may occur in the early postoperative period. The incidence of this complication has been reported to range from 3% to 8% (4). Patients on antithrombotic therapy or with pre-existing coagulopathy undergoing IH surgery have a fourfold increased risk of postoperative secondary bleeding, but despite the extensive dissection required for minimally invasive IH repair, the risk of bleeding complications and complication-related reoperation appears to be lower than open technique (5).

This study aimed to discuss the intraoperative and postoperative early bleeding on transabdominal preperitoneal (TAPP) techniques in IH surgery. We present this article in accordance with the AME Case Series reporting checklist (available at https://ls.amegroups.com/article/view/10.21037/ls-24-15/rc).

Case presentationOther Section

• Introduction
• Case presentation
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

Patients

This report reviews our experience with 262 TAPP hernia repairs over two years. Patients scheduled for laparoscopy are selected based on established guidelines (1). Specifically, a minimally invasive approach is recommended for cases of bilateral hernia, recurrence after open repair, and for athletes, even with unilateral hernia. Patients with inguinoscrotal hernia, prior pelvic surgery or radiotherapy, or contraindications to general anesthesia were excluded (1). Patients are generally discharged on the first postoperative day and are seen for an outpatient follow-up after 10 days. A complete blood count may be performed on the first postoperative day if they exhibit signs or symptoms of anemia. Patients with port site or wound bleeding, such as seroma or ecchymosis development, are excluded. Only patients with clinically and subsequently radiologically evident bleeding and the development of intra or preperitoneal hematoma were included in the study.

Among the series of patients, 3 cases (1.1% of hernia treated) experienced postoperative bleeding necessitating additional interventions such as blood transfusions (1 case), surgical revisions, or angioembolization. Patients were monitored postoperatively to assess the occurrence of complications, as defined by specific therapeutic requirements. The baseline and clinical characteristics of patients are detailed (Table 1).

All patients with complications were under the age of 75 years, 2 men and 1 woman. The two men had bilateral hernias, while the woman had a unilateral femoral hernia. One of them continued aspirin use according to local protocol and established guidelines (1,7).

Operative procedure

A three-ports technique was used. The first port was 10 mm and was positioned in the supraumbilical area on the midline, along with two additional ports of 5 mm each on each flank. If the hernia defects had content, they were reduced and adhesiolysis was performed if necessary. The peritoneum was incised 2 cm above the anterior superior iliac spine extending to the umbilical medial fold using scissors to create the peritoneal flap. Retzius and Bogro’s space was accessed, and subsequent landmarks such as Cooper’s ligament, pubic symphysis, and psoas muscle were exposed. The hernia sac was reduced and the spermatic cord was parietalized. Semi-absorbable polypropylene and poly-L-lactic acid 15 cm × 12 cm (4D anatomical mesh, Cousin) were used in all of our procedures. For very large direct hernias, we favor 17 cm × 12 cm mesh. Nowadays, we tend not to fix the mesh with tacs but only with cyanoacrylate glue. The peritoneal flap is closed with an absorbable barbed suture. The bladder catheter is removed at the end of the procedure before waking up the patient.

Complications

Three patients experienced postoperative bleeding, which was documented with contrast-enhanced abdominal computed tomography (CT) scans (Figures 1-4). Among these cases, Patient 1 presented with venous phase blood extravasation (Figures 1,2), which was successfully managed with angioembolization, leading to resolution without the need for further intervention. Patient 2 received conservative management and was discharged following 3 days of clinical monitoring during hospitalization (Figure 3). Patient 3 required readmission for hematoma evacuation, although definitive sources of bleeding remained unidentified (Figure 4). This patient was discharged after achieving stable hemoglobin levels over 3 days of observation. Among these three patients, only one patient showed signs of anemia severe enough to require blood transfusions.

Figure 1 CT presentation of venous phase blood extravasation (arrow). CT, computed tomography.

Figure 2 Case of Figure 1 after management with angioembolization.

Figure 3 CT scan on conservative management. CT, computed tomography.

Figure 4 CT scan of patient treated with surgical procedure. CT, computed tomography.

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this case series and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

DiscussionOther Section

• Introduction
• Case presentation
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

Laparoscopic TAPP hernia repair has been demonstrated to offer several advantages over open anterior repair. These include reduced postoperative pain, improved cosmetic outcomes, and a faster return to daily activities. While hernia repair can be performed using minimally invasive techniques, intraoperative and postoperative complications including hematomas, bowel and vessel injury, ischemic orchitis, urinary retention, infection, and neuralgia can occur. In the aftermath of TAPP hernia repairs, instances of severe pre-peritoneal or retroperitoneal bleeding may arise on rare occasions (2). However, our findings confirm that this adverse event occurs with a relatively low frequency, following the prevailing guideline (8).

A case series published in 2020 by Gupta et al. analyzed over 200 patients who underwent minimally invasive IH repairs. Three cases of postoperative bleeding occurred, necessitating exploratory laparotomy. It is recommended that the pneumoperitoneum be reduced to 8 mmHg specifically before mesh fixation to enhance visualization and facilitate safer identification of vessels, particularly veins and arteries, thereby reducing the risk of accidental injury (9). In a further case report published by Yasuda et al., a case of massive hemoperitoneum resulting from injury to the “corona mortis” was described. This required surgical revision, thereby emphasizing the importance of meticulous dissection of the retropubic space (2).

Additionally, Ginelliová et al. reported a single case of death due to massive postoperative bleeding after TAPP (3).

The visualization of certain anatomical structures may prove challenging and, in the event of a lack of meticulous surgical technique, there is a risk of injury. This is of particular importance for small vascular structures that nevertheless have significant blood flow due to their origin, such as the round ligament artery and the “corona mortis vessels”. It is important to note that venous injury may be masked by the sealing effect of the intra-abdominal pressure caused by pneumoperitoneum. As observed in a published study by Gupta et al. in 2020, the visibility of arteries and veins in the “corona mortis” can increase from 1.0% and 28.4% to 31.0% and 46.7%, respectively, by reducing the pneumoperitoneum from 14 to 8 mmHg (9).

It is of great importance to maintain an adequate pneumoperitoneum during the evaluation of preperitoneal small vessel injury. It is of particular importance to deflate the preperitoneal space under direct vision to exclude the presence of active bleeding and routinely reduce the pneumoperitoneum at the end of dissection for venous bleeding. By reducing intraabdominal pressure before mesh allocation, one can enhance the visibility of these vessels and may also reduce the risk of not diagnosing injury.

Consequently, in instances of postoperative bleeding, the available management strategies encompass a range of approaches, from conservative measures with close monitoring to interventional radiology techniques such as embolization. Given that laparoscopic management of large hematomas is frequently feasible only with immediate diagnosis, the option of short-stay treatment for these patients should also be considered. The literature on the treatment of these conditions remains limited. If the patient is stable, we suggest, if necessary, a reoperation using a laparoscopic approach, as an anterior approach would involve searching for bleeding in a different plane from the one where the dissection was performed during the initial surgery, making it difficult to identify the exact source of bleeding. However, if the patient is unstable, a more aggressive approach, including pelvic packing, may be necessary. The decision between conservative and operative treatment can be based on various factors. In the case of a stable patient with a small hematoma and no signs of active bleeding on CT, a conservative approach may be considered. If there is contrast agent extravasation on CT, an interventional radiological approach should be considered as an option. In the case of an unstable patient, a large or progressively enlarging hematoma on follow-up imaging, or uncontrolled pain despite medical therapy, surgical re-exploration may be considered, even if only to evacuate the hematoma, as its presence could potentially lead to a prosthetic infection.

The main issue may arise when bleeding occurs days after the surgery and the patient has already been discharged. In such instances, it is crucial to inform patients to promptly return to the hospital for a quick evaluation if they experience symptoms of anemia.

As a preventive measure against bleeding, patients are advised to wear an elastic compression garment for one month after the surgery.

The limitations of the study are that it is a retrospective study with a relatively small sample size. The strengths are that all interventions were performed by the same surgical team in a single center. In the future, more studies with larger sample sizes are needed. Moreover, the patient population is heterogeneous in terms of sex, age, and comorbidities. Further prospective studies with precise inclusion and exclusion criteria could help better predict patients at higher risk of bleeding and potentially guide them toward an open surgery procedure rather than laparoscopic surgery.

ConclusionsOther Section

• Introduction
• Case presentation
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

The findings of our study confirm that laparoscopic IH repair using the TAPP technique is associated with a low incidence of major postoperative bleeding. To mitigate the risk of postoperative hemorrhage, we have implemented, like other authors, several procedural refinements. Specifically, the reduction of pneumoperitoneum upon completion of dissection to inspect for venous bleeding is recommended. Furthermore, surgeons are advised to exercise vigilance during mesh fixation within the retropubic space to prevent injury to the corona mortis vessels. These clinical insights confirm that TAPP represents a safe and well-tolerated approach with a low risk of significant hemorrhagic complications.

AcknowledgmentsOther Section

• Introduction
• Case presentation
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

The authors are grateful all surgeons and nurses from the participating surgical departments for collecting the data.

FootnoteOther Section

• Introduction
• Case presentation
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at https://ls.amegroups.com/article/view/10.21037/ls-24-15/rc

Peer Review File: Available at https://ls.amegroups.com/article/view/10.21037/ls-24-15/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ls.amegroups.com/article/view/10.21037/ls-24-15/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this case series and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

ReferencesOther Section

• Introduction
• Case presentation
• Discussion
• Conclusions
• Acknowledgments
• Footnote
• References

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