Testicular ischemia after inguinal hernia repair using a BARD Hernia Plug (medium), resulting in loss of testicle.. There is also a component of office failure to notify the surgeon of the patients call about extreme testicular pain the next morning.
Time Line:
6-4-19 R and L inguinal hernia repair - R with Bard PlugUHSM mesh.
6-5-19 call to office @ 09:30 high level of testicular pain... told pain normal..
6-5-19 call to office @ 14:46 higher level of pain
6-7-19 ED visit. Determined testical non-viable.
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Do you believe there might have been medical error?
Testicular complications — The incidence of testicular complications ranges from 0.3 to 7.2 percent. Interference with blood supply to the testicle, typically resulting from the dissection of an indirect hernia from the cord structures (open or laparoscopic), can lead to testicular pain, ischemic orchitis, and testicular atrophy. Complications may also result from direct injury, extrinsic compression of cord structures, or a fibrotic reaction to polypropylene mesh. Although this is a known complication, the failure to recognize the problem resulted in the loss of the organ. This is a preventable complication.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
no doubt. The immediate action of the surgeon would have resulted in saving the testicle.
What makes you a good expert for this case?
Teach , train and educate the medical students and residents. Academic appointment at VCU. Very active busy general surgery and colon and rectal surgery practice. Case report Orchiectomy as a result of ischemic orchitis after laparoscopic inguinal hernia repair: case report of a rare complication John B Moore*1 and Erik A Hasenboehler2 Abstract Background: Ischemic orchitis is an established complication after open inguinal hernia repair, but ischemic orchitis resulting in orchiectomy after the laparoscopic approach has not been reported. Case presentation: The patient was a thirty-three year-old man who presented with bilateral direct inguinal hernias, right larger than left. He was a thin, muscular male with a narrow pelvis who underwent bilateral extraperitoneal mesh laparoscopic inguinal hernia repair. The case was complicated by pneumoperitoneum which limited the visibility of the pelvic anatomy; however, the mesh was successfully deployed bilaterally. Cautery was used to resect the direct sac on the right. The patient was discharged the same day and doing well with minimal pain and swelling until the fourth day after surgery. That night he presented with sudden-onset pain and swelling of his right testicle and denied both trauma to the area and any sexual activity. Ultrasound of the testicle revealed no blood flow to the testicle which required exploration and subsequent orchiectomy. Conclusion: Ischemic orchitis typically presents 2–3 days after inguinal hernia surgery and can progress to infarction. This ischemic injury is likely due to thrombosis of the venous plexus, rather than iatrogenic arterial injury or inappropriate closure of the inguinal canal. Ultrasound/duplex scanning of the postoperative acute scrotum can help differentiate ischemic orchitis from infarction. Unfortunately, testicular torsion cannot be ruled out and scrotal exploration may be necessary. Although ischemic orchitis, atrophy, and orhiectomy are uncommon complications, all patients should be warned of these potential complications and operative consent should include these risks irrespective of the type of hernia or the surgical approach.
How often do you encounter cases similar to this one in your practice?
Perform plenty of hernias, many with mesh.
Do you believe there might have been medical error?
The loss of the testicle had to have occurred for one of two reasons: Either the testicular artery was cut, coagulated or damaged within the spermatic cord or a suture was placed around it at some point and thus cut off the circulation to the testicle. One of the most basic precautions when performing a hernia repair is to preserve the blood flow to the testicle. Failure to do so results in testicular death as occurred in this case. This occurrence is a direct effect of a technical mistake at the time of surgery.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The loss of the testicle is a direct result of the damage to the blood flow to the testicle. Testicular loss can't happen without a technical error that interrupts the blood flow.
What makes you a good expert for this case?
Extensive experience in the performance of inguinal hernia repairs with 30 years of surgical experience. Also experienced in forensic cases.
How often do you encounter cases similar to this one in your practice?
Loss of testicle never since it's a rare complication and a direct result of a surgical error. However, the performance of inguinal hernia repairs I perform commonly.
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