Surg Endosc (2010) 24:27082712

DOI 10.1007/s00464-010-1030-1

Complications of laparoscopic inguinal herniorrhaphy including

one case of atypical mycobacterial infection
Julio C. U. Coelho Christiano M. P. Claus
Joao Carlos Michelotto Fabiana Marques Fernandes
Christian Lopez Valle Leonardo Dudeque Andriguetto
Antonio C. L. Campos

Received: 20 June 2009 / Accepted: 2 February 2010 / Published online: 8 April 2010
Springer Science+Business Media, LLC 2010

Abstract
Background Although laparoscopic inguinal herniorrhaphy is considered safe, several complications may occur.
This study aimed to evaluate the complications observed in
780 laparoscopic inguinal herniorrhaphies at the authors
hospital.
Methods All the patients who underwent laparoscopic
inguinal herniorrhaphy at the authors hospital during a
period of 11 years were enrolled retrospectively in this
study. Patient demographics, operative data, and intra- and
postoperative complications were evaluated.
Results A total of 569 patients underwent 780 laparoscopic inguinal herniorrhaphies. The male-to-female ratio
was 8.8 to 1, and the mean age was 54.8 15.7 years.
Hernia recurrence was recognized in 14 patients (2.5%).
Intra- and postoperative complications were diagnosed in
28 (4.9%) and 35 (6.2%) patients respectively. There was
no mortality. The most common intraoperative complication was extensive subcutaneous emphysema. Two patients
with extensive subcutaneous emphysema had cardiac
arrhythmia. Small bowel perforation and bladder perforation occurred in one patient each. One patient had extensive preperitoneal infection caused by Mycobacterium

J. C. U. Coelho (&)
C. M. P. Claus
J. C. Michelotto

F. M. Fernandes
C. L. Valle
L. D. Andriguetto

A. C. L. Campos
Department of Surgery, Hospital Nossa Senhora das Gracas and
Hospital de Clnicas of the Federal University of Parana, Rua
Bento Viana, 1140, Ap. 2202, Curitiba, PR 80240-110, Brazil
e-mail: coelhojcu@yahoo.com.br

123

massiliense, which required mesh removal, tissue

debridement, and prolonged antibiotic therapy.
Conclusions Although the mortality rate is low, potentially life-threatening complications such as small bowel
and bladder perforation may be experienced by patients
subjected to laparoscopic herniorrhaphy.
Keywords Atypical mycobacterium

Bladder perforation
Inguinal hernia

Laparoscopic herniorrhaphy
Small bowel perforation

Inguinal herniorrhaphy is the most common surgical

operation performed by general surgeons, with approximately 750,000 procedures performed annually in the
United States [1]. Since Bassinis [2] report of inguinal
herniorrhaphy in 1887, numerous techniques have been
described. The two most important technical advances in
hernia repair have been the introduction of tension-free
herniorrhaphy with mesh by Lichtenstein et al. [3] in 1989
and laparoscopic inguinal herniorrhaphy by Ger [4] in
1982. Currently, two laparoscopic techniques are used:
transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair.
Laparoscopic inguinal herniorrhaphy has gained worldwide acceptance, becoming the first choice for inguinal
hernia repair in many centers [58]. This procedure has
several advantages including less postoperative pain, a
short recovery period, a rapid return to normal activities,
better cosmetic results, and a low recurrence rate.
Although laparoscopic inguinal herniorrhaphy is considered safe, several complications have been described
[79]. Our current study aimed to describe the complications
observed with 780 laparoscopic inguinal herniorrhaphies at
our hospital.

Surg Endosc (2010) 24:27082712

Patients and methods

The study protocol for all the patients who underwent
laparoscopic inguinal herniorrhaphy in the Department of
Surgery at the Hospital Nossa Senhora das Gracas, Curitiba, Brazil, from August 1998 to December 2008 was
retrospectively reviewed. The study was approved by the
ethics committee of our hospital.
The following data were obtained and analyzed: age,
gender, history of prior inguinal herniorrhaphy, operative
findings, operative procedure, duration of operations, intraand postoperative complications, length of hospital stay,
and recurrence. Patients were followed routinely up to
3 months after the operation. The follow-up period was
extended for patients with complications or hernia
recurrence.
The laparoscopic procedure used was the modified
technique described by Dulucq [10] in 1991. Briefly, the
operation consisted of a TEP repair, in which a 10 9 10-cm
to 10 9 15-cm mesh was secured on the posterior aspect
of the abdominal wall by intraabdominal pressure alone,
with no fixation (sutureless).
Carbon dioxide (CO2) was initially insufflated into the
suprapubic space of Retzius through a Veress needle
inserted into the midline just above the pubis. Three trocars
(a 10-mm infraumbilical, a 5-mm left-flank, and a 10-mm
right-flank trocar) were used with no balloon dissector. A
3-cm slit in the mesh was made to accommodate the
spermatic cord. A single dose of cephazolin was given at
anesthesia induction. No gastric tube or urinary catheter
was used.
Whenever the TEP procedure could not be performed
due to technical difficulties, the TAPP procedure (n = 15),
open Lichtenstein procedure (n = 6), or McVay technique
(n = 1) was used. In addition to herniorrhaphy, laparoscopic vasectomy was performed during spermatic cord
dissection for 9 men.
The patients returned for ambulatory follow-up assessment on day 7, then 1 and 3 months after the operation.
The follow-up period was extended for patients with
complications or clinical manifestations. Values are
expressed as mean standard deviation.

Results
During the study period, 569 patients were subjected to 780
laparoscopic inguinal herniorrhaphies. Table 1 shows the
patient demographics and hernia characteristics.
The male-to-female ratio was 8.8 to 1, and the mean age
was 54.8 15.7 years. Although unilateral hernia was the
more common disorder, 211 patients (37.1%) had bilateral

2709
Table 1 Patient demographics and hernia characteristics
Demographics/characteristics

No. of patients

569

No. of hernias

780

Mean age (years)

54.8 15.7

Range

1495

Gender
Male

511

89.8

Female

58

10.2

Right

185

32.5

Left

173

30.4

211

37.1

Direct

343

44.0

Indirect

402

51.5

Direct ? indirect

29

3.7

Femoral

0.8

31

5.4

Site of hernia

Bilateral
Type of hernia

Recurrent hernia

hernia. Recurrent hernias necessitated the operation in 31

patients (5.4%).
The mean operative time was 24 8 min for the unilateral hernias and 32 9 min for the bilateral hernias.
Most of the patients (n = 505, 88.8%) were discharged
from the hospital on the same day of the operation. However, 59 patients (10.4%) were discharged on postoperative
day 1 and 5 patients (0.9%) on postoperative days 2 to 5.
Hospital readmission was needed by 22 patients (3.9%).
Almost all the patients (n = 540, 94.9%) had a followup period of at least 3 months. Hernia recurrence was
diagnosed in 14 patients (2.5%). Most recurrences
(n = 10) occurred in the first 2 months.
Intra- and postoperative complications occurred in 28
(4.9%) and 35 (6.2%) patients, respectively. There was no
mortality. The incidences for all the complications are
shown in Table 2.
The most common intraoperative complication was
extensive subcutaneous emphysema. Mild or moderate
subcutaneous emphysema was common, but it was selflimited, had no clinical significance, and lasted only a short
time, usually less than 1 h. However, 15 patients (2.6%)
had severe emphysema that extended to the thorax and
face, causing important swelling. These 13 patients had no
intercurrent condition except for hypercarbia, which was
treated by increasing the ventilation rate.
Two patients with extensive subcutaneous emphysema
and a history of cardiac insufficiency had extrasystoles,
which were treated with temporary interruption of CO2
insufflation. Thereafter, the surgical procedure was

123

2710

Surg Endosc (2010) 24:27082712

Table 2 Intra- and postoperative complications (n = 569)

n

Intraoperative complications
Extensive subcutaneous emphysema

15

2.6

Inferior epigastric vessel injury

1.4

Spermatic vessel injury

0.4

Urinary bladder injury

0.2

Small bowel injury

0.2

Pneumaturia

0.2

12

2.1

Pulmonary atelectasis

1.1

Wound infection
Large hematoma

5
5

0.9
0.4

Urinary infection

0.4

Chronic pain

0.2

Pneumonia

0.2

Thrombophebitis

0.2

Mesh infection

0.2

Postoperative complications
Urinary retention

completed successfully with reduction of the CO2 insufflation pressure to 10 mmHg.

Eight patients (1.4%) experienced inferior epigastric
vessel injury at either trocar insertion (n = 6) or areolar
tissue dissection of the preperitoneal space (n = 2). All
these vessel injuries were easily controlled by clipping. The
mean blood loss experienced by these patients was
100 60 ml (range, 50400 ml). No patient needed blood
transfusion.
Two patients (0.4%) had spermatic vessel injury during
dissection of the hernia sac of a large indirect inguinal
hernia. The bleeding was minimal and easily controlled
with electrocauterization. No testicle atrophy was observed
in the postoperative follow-up period. One patient who had
undergone open radical prostatectomy experienced pneumaturia and spontaneous micturition at surgery due to
Veress needle insertion and CO2 insufflation into the
bladder at the beginning of the procedure. After repositioning of the needle, CO2 insufflation at the preperitoneal
space was successful. No bladder suture was needed, and
the patient had an uneventful recovery with no
complication.
One patient had a 1-cm perforation of the bladder during
blunt preperitoneal dissection. The lesion was promptly
recognized by urine extravasation and treated with twolayer intracorporeal suturing. This patient had undergone
opened radical prostatectomy 4 years earlier.
One patient experienced small bowel perforation during
sac dissection of an incarcerated femoral hernia. The procedure was converted to an open operation. After enterectomy, the femoral hernia was repaired using the McVay

123

technique with no mesh placement. Both patients with

bladder and bowel injuries had uneventful recoveries.
Urinary retention that required catheterization was
experienced by 12 patients (2.1%). Two of these patients
experienced urinary infection, which was treated with
antibiotics.
Six patients (1.1%) had fever on postoperative days 2
and 3. Chest radiography confirmed the presence of basal
atelectasis, which was treated with antipyretics and respiratory physiotherapy.
Superficial wound infection at the infraumbilical trocar
insertion site was recorded for five patients (0.9%) and
treated using local dressing with povidone-iodine. No
antibiotic was used. Five patients (0.9%) with a large
inguinal hematoma and significant discomfort needed
blood aspiration percutaneously (450 50 ml).
Two patients (0.4%) referred intense pain in the inguinal
area that began 2 to 3 months after the operation. The pain
was triggered by sexual intercourse, mainly at orgasm, and
lasted for 3 to 4 h. Neither clips nor sutures had been used
at herniorrhaphy. No cause for the pain was identified after
exhaustive investigation at the Division of Urology. Several laboratory and radiographic exams were normal
including a spermogram, cultures, and magnetic resonance.
The pain was controlled with analgesics and disappeared
gradually 1 year after the operation.
One patient presented with mild inflammatory signs
6 cm above the pubic symphysis 3 months after bilateral indirect inguinal hernia repair. The local findings
were erythema, local warmth, painful nodules, and
minimal purulent discharge from a deep fistulous tract.
No improvement was observed after 10 days of treatment using local dressings with povidone-iodine.
Microscopic examination of biopsy material showed
acid-fast bacilli in Ziehl-Neelsen-stained smears. Culture results were positive for mycobacteria. Polymerase
chain reaction (PCR)-restriction-enzyme analysis of the
hsp65 gene, pulsed field gel electrophoresis (PFGE),
and rpoB partial gene sequencing identified Mycobacterium massiliense.
The patient underwent mesh removal through a 10-cm
midline infraumbilical incision. Extensive granulomatous
inflammatory tissue was present in the preperitoneal pelvic
area, including the area around the iliac vessels and the
bladder. This tissue was carefully and thoroughly debrided.
The transversalis fascia and transversus abdominis aponeurosis were sutured to the iliopubic tract bilaterally
(preperitoneal repair). The antibiotic scheme consisted of
clarithromycin, amikacin, and minociclin for 3 months, and
thereafter, clarithromycin, minociclin, and moxifloxacin.
Ultrasonography and magnetic resonance were performed periodically until complete resolution of the
inflammatory process 15 months later. Antibiotics were

Surg Endosc (2010) 24:27082712

maintained for 3 additional months. The patient had a full

recovery with no hernia recurrence.
Thrombophebitis and pneumonia occurred in one patient
each. These complications were treated successfully with
low-weight heparin and antibiotics, respectively.

Discussion
In the first years after its introduction, laparoscopic inguinal herniorrhaphy was controversial due to the early high
recurrence rate and occurrence of complications. With
several technical modifications, mainly the introduction of
the TEP repair, this procedure gained worldwide acceptance [1113]. The TEP approach is considered superior to
TAPP because it is less invasive and associated with fewer
complications due to the fact that the peritoneal cavity is
not entered [1416].
Most intra- and postoperative complications are minor
and self-limited, needing no specific treatment. As in the
experience of Dulucq et al. [15], our most frequent
intraoperative complication was extensive subcutaneous
emphysema. Mild subcutaneous emphysema is very common but has no clinical importance because it is reabsorbed
in a short time. However, extensive subcutaneous emphysema may cause hypercarbia and respiratory acidosis due
to a large area of CO2 absorption [1719]. It may be easily
treated by increasing the ventilation rate. This complication
may be avoided by using CO2 insufflation pressure to a
maximum of 12 mmHg.
Hematoma and seroma may occur mainly after repair of
a large hernia, in which extensive dissection is necessary to
reduce the hernia sac. The large emptying space created by
sac reduction may be filled with blood, serum, or both.
Usually, the fluid will be absorbed in few weeks with no
further complication. However, some patients may need
aspiration of fluid to treat local discomfort. In addition,
infection and abscess may ensue in a few patients [16].
Lesion of the spermatic cord elements may occur during
laparoscopic herniorrhaphy. We had only minor vessel
injuries, which were controlled easily using electrocauterization, with no further complication. However, more
extensive lesions have been described by others [15].
Bilateral lesion of the spermatic cord may cause infertility.
Other causes of infertility experienced by patients who
underwent inguinal herniorrhaphy include cauterization
injury, vas deferens ligation, vascular injuries, and
obstruction of spermatic cord elements by a dense fibroblastic inflammatory reaction caused by the mesh [20]. The
incidence of lesion to the spermatic cord elements caused
by laparoscopic inguinal herniorrhaphy is not known
because invasive diagnostic studies such as vasography are
necessary to determine the actual frequency of such

2711

injuries [20]. Some studies suggest that the incidence of vas

deferens injury after open inguinal herniorrhaphy varies
from 0.3% to 7.2% [21, 22].
Atypical or nontuberculous mycobacteria (NTM) usually are saprophytes but may be an infrequent cause of
surgical infection in humans. These organisms may be
found in hospital tap water, chlorine, organomercurial
agents, and liquid surgical material disinfectants such as
glutaraldehyde [23]. Hospital outbreaks of NTM infections
have been recognized sporadically. There are reports of
NTM infections after several types of surgical procedures
including pacemaker placement and subcutaneous injections as well as plastic, cardiac, ophthalmologic, and general surgery operations [2428].
One of our patients had an extensive pelvic and lower
abdominal preperitoneal infection caused by an NTM after
a bilateral inguinal herniorrhaphy. The infection was
caused by contamination of laparoscopic instruments with
Mycobacterium massiliense during liquid sterilization with
glutaraldehyde. An outbreak of M. massiliense infection
occurred in our city at the time of the herniorrhaphy. Our
state Secretary of Health recorded NTM infection in 82
patients who underwent laparoscopic surgical procedures
during a period of 2 months. It was established by PFGE
analysis and hsp65 and rpoB gene sequencing that glutaraldehyde contamination by M. massiliense was responsible
for all the infection cases.
Although glutaraldehyde achieves high-level disinfection but not sterilization, this agent has been used for
reprocessing laparoscopic instruments in many centers
[29]. It has been demonstrated that inadequate mechanical
cleaning of surgical instruments may lead to biofilm formation and facilitate the occurrence of outbreaks [30].
Other methods used for reprocessing laparoscopic instruments include hydrogen peroxide, acetic acid, orthophthaldehyde, surfacine, and superoxidized water [31].
In our patient, the time from the surgical procedure to
the microbiologic diagnosis of NTM was 3 months. The
period reported in the literature varies from 1 to 14 months
[25]. Delayed diagnosis may increase morbidity. Extensive
debridement may be necessary due to infection dissemination when the diagnosis is delayed. Clinical presentation
usually is surreptitious. It usually takes several weeks or
months for the clinical manifestations of NTM infection to
be evident.
Diagnosis also may be delayed because of incomplete or
inadequate microbiologic testing. Histopathologic examination shows granulomatous inflammation with either a
foreign body or a tuberculous type of reaction. Acid-fast
bacilli also may be identified. Culture of the debrided tissue
is the most reliable method for diagnosis [26].
Treatment of NTM infection should include wide excision
or extensive debridement of all lesions, which usually contain

123

2712

several fistulous tracts and satellite abscesses that penetrate

much deeper than can be appreciated from the surface [24].
An association of two or three antibiotics for long periods,
usually 6 to 12 months, is necessary to ensure complete
wound healing and to prevent recurrence [24]. The antibiotic
scheme used for our patient was recommended by our state
Secretary of Health based on in vitro sensitivity tests.
Although mortality is potentially life threatening, complications such as small bowel and bladder injuries may
occur in patients subjected to laparoscopic herniorrhaphy.
These complications are observed more frequently in
patients with large or incarcerated hernia and those who
have undergone previous operations in the lower abdomen.
In these conditions, more dissection and traction are needed
to identify and free the hernia sac from firm and intense
adhesions.
Disclosures Julio C. U. Coelho, Christiano M. P. Claus, Joao Carlos
Michelotto, Fabiana Marques Fernandes, Christian Lopez Valle,
Leonardo Dudeque Andriguetto, and Antonio C. L Campos have no
conflicts of interest or financial ties to disclose.

References
1. Rutkow IM (1998) Epidemiology, economic, and sociologic
aspects of hernia surgery in the United States in the 1990s. Surg
Clin North Am 73:413426
2. Bassini E (1987) Sulla cura radicale dellernia inguinale. Arch
Soc Ital Chir 4:380
3. Lichtenstein IL, Shulman AG, Amid PK, Montloor MM (1989)
The tension-free hernioplasty. Am J Surg 158:188193
4. Ger R (1982) The management of certain abdominal hernias by
intraabdominal closure of the neck of the sac: preliminary communication. Ann R Coll Surg Engl 64:342344
5. Felix EL, Michas CA, Gonzales MH Jr (1995) Laparoscopic
hernioplasty: TAPP vs TEP. Surg Endosc 9:984989
6. Agarwal BB, Agarwal KA, Mahajan KC (2009) Prospective
double-blind randomized controlled study comparing heavy- and
lightweight polypropylene mesh in totally extraperitoneal repair
of inguinal hernia: early results. Surg Endosc 23:242247
7. Mazeh H, Beglaibter N, Grinbaum R, Samet Y, Badriyyah M,
Zamir O, Freund HR (2008) Laparoscopic inguinal hernia repair
on a general surgery ward: 5 years experience. J Laparoendosc
Adv Surg Tech A 18:373376
8. Kouhia ST, Huttunen R, Silvasti SO, Heiskanen JT, Ahtola H,
Uotila-Nieminen M, Kiviniemi VV, Hakala T (2009) Lichtenstein hernioplasty versus totally extraperitoneal laparoscopic
hernioplasty in treatment of recurrent herniaa prospective
randomized trial. Ann Surg 249:384387
9. Philips EH, Arregui M, Carroll BJ, Corbitt J, Crafton WB, Fallas
MJ, Filipi C, Fitzgibbons RJ, Franklin MJ, McKernan B (1995)
Incidence of complications following laparoscopic hernioplasty.
Surg Endosc 9:1621
10. Dulucq J-L (1991) Traitement des hernies de laine par la mise en
place dun patch prothetique par laparoscopie: voi totalement
extraperitoneale. Cah Chir 79:1516
11. Bowne WB, Morgenthal CB, Castro AE, Shah P, Ferzli GS
(2007) The role of endoscopic extraperitoneal herniorrhaphy:
where do we stand in 2005? Surg Endosc 21:707712

123

Surg Endosc (2010) 24:27082712

12. Ramshaw B, Shuler FW, Jones HB, Duncan TD, White J, Wilson
R, Lucas GW, Mason EM (2001) Laparoscopic inguinal hernia
repair: lessons learned after 1,224 consecutive cases. Surg Endosc
15:5054
13. Spitz JD, Arregui ME (2000) Sutureless laparoscopic extraperitoneal inguinal herniorrhaphy using reusable instruments: two
hundred three repairs without recurrence. Surg Laparosc Endosc
Percutan Tech 10:2429
14. Kald A, Anderberg B, Smedh K, Karlsson M (1997) Transperitoneal or totally extraperitoneal approach in laparoscopic hernia
repair: results of 491 consecutive herniorrhaphies. Surg Laparosc
Endosc 2:8689
15. Dulucq J-L, Wintringer P, Mahajna A (2009) Laparoscopic
totally extraperitoneal inguinal hernia repair: lessons learned
from 3,100 hernia repairs over 15 years. Surg Endosc 23:482
486
16. Jarhult J, Hakanson C, Akerud L (1999) Laparoscopic treatment
of recurrent inguinal hernias: experience from 281 operations.
Surg Laparosc Endosc 9:115118
17. Streich B, Decailliot F, Perney C, Duvaldestin P (2003) Increased
carbon dioxide absorption during retroperitoneal laparoscopy. Br
J Anaesth 91:793796
18. Liem MSL, Kallewaard J-W, Smet AMGA, vanVroonhovem
TJMV (1995) Does hypercarbia develop faster during laparoscopic herniorrhaphy than during laparoscopic cholecystectomy?
Anesth Analg 81:12431249
19. Lew YS, Thambi-Dorai CR, Phyu PT (2005) A case of supercarbia following pneumoperitoneum in an infant. Paediatr Anaesth 15:346349
20. Shin D, Lipshultz LI, Goldstein M, Barme GA, Fuchs EF, Nagler
HM, McCallum SW, Niederberger CS, Schoor RA, Brugh VM
3rd, Honig SC (2005) Herniorrhaphy with polypropylene mesh
causing inguinal vasal obstruction. Ann Surg 241:553558
21. Pollack R, Nyhus LM (1983) Complications of groin hernia
repair. Surg Clin North Am 63:13631370
22. Hendin BN, Sheynkin YR, Schlegel PN, Goldstein M (1998)
Microsurgical repair of iatrogenic injury to the vas deferens.
J Urol 159:139141
23. Griffiths PA, Babb JR, Bradley CR, Fraise AP (1997) Glutaraldehyde-resistant Mycobacterium chelonae from endoscope
washer disinfectors. J Appl Microbiol 82:519526
24. Muthusami JC, Vyas FL, Mukundan U, Jesudason MR, Govil S,
Jesudason SRB (2004) Mycobacterium fortuitum: an iatrogenic
cause of soft tissue infection in surgery. ANZ J Surg 74:662666
25. Cardoso AM, Sousa EM, Viana-Niero C, Bortoli B, Neves ZCP,
Leao SC, Junqueira-Kipnis AP, Kipnis A (2008) Emergence of
nosocomial Mycobacterium massiliense infection in Goias, Brazil. Microb Infect 10:15521557
26. Plaus WJ, Hermann G (1999) The surgical management of
superficial infections caused by atypical mycobacteria. Surgery
110:99103
27. Vijayaraghavan R, Chandrashekhar R, Sujatha Y, Belagavi CS
(2006) Hospital outbreak of atypical mycobacterial infection of
port sites after laparoscopic surgery. J Hosp Infect 64:344347
28. Sethi NK, Aggarwal PK, Duggal L, Sachar VP (2003) Mycobacterium chelonae infection following laparoscopic inguinal
herniorrhaphy. J Assoc Physicians India 51:8182
29. Fuselier HA, Mason C (1997) Liquid sterilization versus highlevel disinfection in the urologic office. Urology 50:337340
30. Goller CC, Romeo T (2008) Environmental influences on biofilm
development. Curr Top Microbiol Immunol 322:3766
31. Rutala WA, Weber DJ (2001) New disinfection and sterilization
methods. Emerging Infect Dis 7:348353

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.