What are NOT ‘Hernia Complications’ After Hernia Surgery?

I want to start by differentiating expected post operative changes and issues with the word ‘hernia complication’. Every patient after hernia surgery is likely to encounter a number of expected things:

• bruising – sometimes this can occur in areas well outside of the surgical area
• swelling- most patients will have moderate to significant swelling for 1-2 weeks after surgery
• nausea – although uncommon, some patients react to anesthesia differently than others
• pain – all patients should expect some level of pain and discomfort after any type of surgical procedure
• difficulty urinating – a small percentage of patients will have difficulty urinating after surgery due to anesthetics
• allergic reaction – rashes, hives, or other manifestations of an allergy to a medications

These findings are not considered hernia complications because they are expected in a majority, or even a small but reasonable percentage of patients. They also are self limiting, meaning that they will resolve on their own without any specific additional treatment. In addition, they do not cause any long term sequela, or any long term ‘complications’.

What ARE Complications?

A hernia complication is something that is not expected to happen after hernia surgery. Keep in mind that even though it isn’t ‘expected’, all complications are know to be a possibility, no matter how rare. Some complications may require a follow up procedure to be performed to help treat the complication. Complications can sometimes cause long term problems, or can lead to a prolonged recovery after surgery.

The following table demonstrates the known hernia complications that can occur after hernia surgery and their associated chance of occurring. Keep in mind that this table only provides the incidence of complications in normal, healthy patients. Some patients with obesity, diabetes, large chronic hernias, recurrent hernias, or prior infected hernias may have a higher incidence of having a complication after surgery.

(the ‘Expected Incidence’ is the number of hernia surgeries performed for this to happen one time. These numbers are averages based on the best available medical data and are not absolute.)

Although I take a personal responsibility for patients who develop any of these complications, I also discuss with my patients that complications can occur after ANY surgery. Patients who have knee surgery, back surgery, shoulder surgery, or ANY surgery for that matter, have a risk of developing a complication like the ones listed above. Thus, complications are NOT limited to just hernia surgery. There is no way that any type of surgeon can guarantee that 100% of their patients are going to have a 100% perfect outcome. The goal that I have, and most high volume surgeons have, is to minimize the factors that we know can affect the outcome for our patients, including everything from reducing pain to infections.

Timeline for Hernia Complications

The various hernia complications occur at different times after surgery. This table shows when the complication is most likely to occur. Sometimes, these complications can present over a very long period of time.

What Steps Do I Take to Minimize Hernia Complications?

One important concept to remember is that NO surgeon, of any type, can ensure that 100% of their patients will have NO complications. This goes for myself, as well as doctors at famous hospitals across the country. The saying in surgery is – “if you don’t have any complications, you’re not operating”. And clearly this rule applies to myself as well. In most instances, the root cause of a patient developing a complication isn’t something easily identified during surgery. If that was the case, then we would be able to eliminate any possible complication. This means that despite our best efforts during surgery, we don’t always know what went ‘wrong’. Thus, there isn’t one technique, or one maneuver that will ensure that patients won’t develop a complication. And again, this applies to my techniques and to my outcomes. However, applying some basic principles, there are some things that I try to do to help ensure that patients have the best outcomes.

1. I recognize that a complication is always a possibility, and I treat each surgery with absolute care. This may sound a bit unusual, but without the insight that something could go wrong, and the desire to avoid that outcome, having success will be impossible. Unfortunately there are plenty of professionals in all fields who don’t care, and are just going through the motions. This doesn’t apply to my medical practice or to any of the surgeries I perform each day. Hernia surgery is not an afterthought.

2. The use a set post operative instructions and our post operative recovery chart helps patients understand what to do, and more important, what NOT to do after surgery. Again, a complication isn’t easily identifiable to any one cause. Thus, if I can help patients minimize their impact on complications, then we can reduce the overall rate of complications to as low as reasonably possible. Patients who rest after surgery for 3-4 days might reduce their chance of a hematoma. Those patients who follow our instructions and refrain from lifting heavy objects for 3 weeks may reduce their chance of a recurrent hernia. Of course not all complications are due to patient factors; some are clearly something that we should have done better as the surgeon. But, reducing the patients impact on complications, reduces complications!

3. Over many years and through 1000’s of hernia repairs, high volume surgeons develop an eye for issues that could possibly cause a complication after surgery. Some of these may not be issues at all, but the only way to ensure the best outcomes is to try and make the entire surgery as smooth as possible. Avoiding nerves, preventing bleeding, using the correct type and size mesh, minimizing the amount of dissecting of the normal healthy tissues can all lead to subtly better outcomes. Again, no surgeon can know exactly what step caused a complication, but by following a routine that works 99% of the time, high volume surgeons can provide a more reliable outcome over surgeons who only perform the procedure occasionally.

How to Minimize Recurrent Hernias

Although patients often cannot affect their risk of developing a primary (first time) hernia, they actually can impact their development of a recurrent hernia. Recurrent hernias are ones that form after a surgeon has already attempted to repair the primary hernia. This can happen as early as days/weeks after the first surgery, or as long as decades. Regardless, there are important steps a patient can take to minimize their chances of having a recurrent hernia. The best way a patient can help prevent a hernia recurrence is to find a surgeon who performs a high volume of hernia surgeries. This volume of surgeries clearly imparts a high level of surgical experience which can reduce a patients chance at developing a recurrent hernia. The risk factors for recurrent hernias your choice of surgeon can influence includes:

• Low surgical volume of hernia repairs by the surgeon performing the initial operation
• Surgical inexperience of the initial surgeon
• Open hernia surgery under local anesthesia
• Insufficient surgical technique of the surgeon including:
  1. lack of mesh overlap
  2. improper mesh choice
  3. lack of proper mesh fixation

The HerniaSurge group’s International Guidelines point to at least 4-5 different risk factors for hernia recurrence which are influenced by a patients surgeon. The best way a patient can help prevent a hernia recurrence is to find a surgeon who performs a high volume of hernia surgeries. This volume of surgeries clearly imparts a high level of surgical experience which can reduce a patients chance at developing a recurrent hernia.

Patients can read more from the International Guidelines for Inguinal Hernias here:

What is Your Next Step?

The most important aspect of decision making for patients, is to balance the risks and benefits of each option. Some patients would feel that avoiding surgery and just watching their hernia would provide to serious a limitation on their lifestyle and activity. Thus, the benefit of observation would far outweigh the risks. Another patient may feel that their hernia is causing no issues and that any possible complication is too risky to warrant surgery. Those patients should choose to just observe their hernia. Regardless of what direction you want to take, it’s important to know what the true incidence of complications are in hernia surgery so that you can make an educated decision!