A 60-year-old patient underwent an ultrasound of his scrotum and its contents after complaining of right testicular pain for some time. The ultrasound was read as unremarkable, but the patient apparently believed he had an inguinal hernia nonetheless. Eventually he saw a general surgeon, who confirmed that he did, and agreed to do a hernia repair surgery with mesh. The consent signed by the patient was for a "laparoscopic right inguinal hernia repair, possible left." According to the patient, the surgeon told him that 30% of men are born with hernias on their left side, and that he would check during the surgery to see if the patient had one that also needed repair.
The operative report states in part as follows: "... Attention was turned to the right side where the peritoneum was dissected at the level of the anterior-superior iliac spine. It was followed to the internal ring. The peritoneum was dissected off the cord structures and dissected deep into the pelvis. There was also evidence for a small direct hernia. The preperitoneal fat was dissected off the pseudosac of the direct space. Attention was turned to the left side. The peritoneum was dissected to the level of the anterior superior iliac spine. The peritoneum did not traverse the inguinal ring however there was a significant cord lipoma that was reduced from the internal ring. The peritoneum was dissected off the cord structures. There was no direct hernia on the left side...."
Large 3DMax mesh was used to repair both sides. The patient went on to have numerous complications that he attributes to the mesh, and he eventually had it removed about a year later. The patient believes that the surgeon was wrong to put mesh on the left side in particular, because he believes that he never had a hernia there.
Files:
Q: What problems or complications did they patient experience?
A: —
Do you believe there might have been medical error?
A key element of this case is the fact that the operative report of the case specifies that there was a cord lipoma that was reduced from the internal ring. As such, whether this was true or not, this is the only evidence that we have to determine indeed if there was a left hernia or not, and it suggests there was one. Whether the complications themselves could indicate an error is a different question that needs careful record review to determine.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Mesh can cause problems even when there is no clear error occurring. These problems could be infections or nerve pain. Recurrence can also occur. I am not sure I see there is clear causation from the little information we have here. Perhaps review of records leads to a different conclusion.
What makes you a good expert for this case?
I do inguinal hernia repair as part of my practice in a large busy academic hospital, and have published a few articles related to inguinal hernia. I am a nationally recognized authority in patient safety and quality.
How often do you encounter cases similar to this one in your practice?
yes, related to inguinal hernia complications
Do you believe there might have been medical error?
Patients with cord lipomas can present with inguinal pain and perhaps a protrusion or mass, mimicking a hernia or with similar symptoms. A significant cord lipoma is a reasonable indication to carry out a repair on an asymptomatic side when you are already operating on the other side (this is a matter of judgement at the time of surgery - depending on the findings. To do the dissection and not place mesh to prevent a hernia from developing could result in a post-op hernia, so doing the exploration pretty much commits the surgeon to doing a repair.. I don't have any details on the nature of the complications from the mesh but such complications do occur routinely and do not represent negligence. If surgeon told the patient he was going to explore if there was a question and put in mesh if he found something, then proper consent was obtained. To me this represents possible errors in judgement (easy to say in retrospect), But not negligence. .
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
please see my narrative above related to causation
What makes you a good expert for this case?
I do hernias routinely in my practice. So this is in my area of expertice.
How often do you encounter cases similar to this one in your practice?
I see similar cases often enough
Do you believe there might have been medical error?
The presence of a cord lipoma does indicate the presence of a hernia. It is stated in the dictation that the peritoneum did not traverse the inguinal ring which indicated that no hernia was present even by the surgeon’s own description. Additionally, 30% of men do not have left sided hernias.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is not stated what the specific complications were but if mesh was placed to fix a nonexistent hernia, then any complications related to the mesh could have been avoided by not placing it.
What makes you a good expert for this case?
I am board certified in general surgery and critical care and serve as the medical director for acute care surgery at a verified level one trauma center. I do many elective and emergent inguinal hernias open, laparoscopically and with the robot.
How often do you encounter cases similar to this one in your practice?
I frequently see elective and emergent inguinal hernias and complications related to previous inguinal surgery. I address these complications with mesh removal or an occasional neurectomy for intractable inguinodynia.
Do you believe there might have been medical error?
It is not uncommon to repair both sides, especially with a large cord lipoma that was seen and removed as dictated in the operative note. In addition, more likely than not whether the mesh was only covering the right side, or both the right and left side. The same complications would have occurred.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Mesh complications are extremely common. Placement of mesh for inguinal. Hernia pairs has become standard of care. Was there anything in the operative note stating it was done incorrectly or tacked in the wrong area or did the patient need further surgery? That really is the crux of this case. Not the complication, but was the complication avoidable or preventable based on standard of care
What makes you a good expert for this case?
Board-certified in general and Colorectal Surgery. Lots of experience operating on these types of patients taking care of them both Preop and postoperatively.
How often do you encounter cases similar to this one in your practice?
Inguinal hernias are one of the more common things that we see
Do you believe there might have been medical error?
There is a high association between lipoma of the cord and inguinal hernias, both at the time of findings and future risk. Therefore, there is a strong argument to treat lipoma of the cord when found intra-operatively. That being said, it is likely the patient's post-operative symptomatology is related to the surgical intervention. I would need to review the chart in detail to see exactly what symptoms the patient experienced post-operatively as well as review the intra-operative techniques described to see if this could have been a preventable outcome versus a complication associated with the surgery.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above, if the symptomatology is related to the mesh (IE compression of the ileoinguinal nerve, local reaction from the mesh, entrapment from the suture technique during surgery), than there may have been causation for this patient's post-operative symptoms. However, it is also possible that the patient's symptoms/complications occurred despite an acceptable surgical approach, and thus would be part of the informed consent process he signed prior to surgery.
What makes you a good expert for this case?
I routinely manage inguinal hernias as part of my practice both in the elective and emergent setting. I am well versed in the techniques and complications associated with the surgery and would be comfortable reviewing this patient's case in detail for opportunities for improvement in the surgical technique if applicable as well as discerning whether this was a preventable outcome versus a complication within the reasonable realm of the procedure.
How often do you encounter cases similar to this one in your practice?
This is not a common complication-usually about 5-10% incidence. However, I have seen multiple mesh related complications throughout the course of my career.
Do you believe there might have been medical error?
In the performance of the left inguinal dissection he identified a lipoma of the cord which is preperitoneal fat in the pelvis. Once does not close the internal ring so if once reduces the fat but does not place a mesh in the space the lipoma can again go down the ring and over time grow larger and palpable and the patient would indeed have a palpable hernia. So for this reason it would be hard to simply reduce the lipoma on the left and not place a mesh. The only caveat it one might argue if the patient had no complaints on the left and no hernia palpable on a preoperative examination there is no strong indication to "check" the other side. I believe it is best to repair the symptomatic hernia with mesh and if there is no hernia on the left identified preoperatively to NOT explore the other side just repair the symptomatic hernia you came for (with mesh). By leaving the other side alone there might be a 30% chance of getting a contralateral hernia in the future but if one had a good experience with the once repair could then return back to the surgeon to do the other side (new hernia). This is what I commonly due in my practice. Exploring the other side is something done in children by pediatric surgeons and although some may advocate for it it is not common practice in adults. The algorithm is as I described above if the hernia is unilateral on preop evaluation just fix the one side and leave the other side alone.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I believe one might be able to argue that exploring the other side in a patient who has no complaints related to the left groin and no documented hernia on examination preoperatively- SHOULD NOT have the left groin explored. Again in my practice and in most of the surgeons in my institution I know none who "explore" the other side just in case - if all there is is a unilateral symptomatic hernia they only repair that. There is however some literature extolling the benefit of exploring the other side even in adults (especially patients > 70 or with health issues where one would not want to return them to the OR if they develop another hernia in the future). But again most surgeons do not explore the other side but it is described and done my a minority. But as I mentioned once you reduce a lipoma it would be difficult to not place a mesh.
What makes you a good expert for this case?
I serve as the surgical quality officer at a major urban hospital and for more than a decade have performed reviews of all morbidities and internal review of malpractice cases in a busy department of surgery. In addition I have been performing legal reviews of cases for 6 years now and typically am reviewing 2-3 cases at any given time and have written expert reports and been deposed as an expert. My clinical practice involves a large number of hernia surgeries.
How often do you encounter cases similar to this one in your practice?
My practice involves a large number of hernia repair both laparoscopically as well as open. I used mesh in the majority of my inguinal hernia surgeries. I have also trained fellows and residents in the proper performance of open and laparoscopic inguinal hernia repairs.
Do you believe there might have been medical error?
There is no indication to put a mesh when no hernia existed. While hernia repair with mesh on the right side was indicated, with only a lipoma on the left side there is no indication to place a mesh.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The more the mesh the greater the risk of infection and entrapment of nerves and complications. So I would conclude that mesh repair on left side definitely increased risk of complications.
What makes you a good expert for this case?
Repair a lot of hernias and selectively use mesh to repair hernias.
How often do you encounter cases similar to this one in your practice?
Often. While exploring the other side is certainly indicated. There is no role to repair the side with no hernia.
Do you believe there might have been medical error?
I would want more details about the patient's "complications" after the surgery. The entire operative report would be helpful. The current standard of care is to only fix an inguinal hernia IF it is symptomatic. It appears that the LEFT inguinal hernia was asymptomatic. Which makes me wonder if the this was the habit of the surgery to bill at a higher level.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I would want more details about the patient's "complications" after the surgery. The entire operative report would be helpful. The current standard of care is to only fix an inguinal hernia IF it is symptomatic. It appears that the LEFT inguinal hernia was asymptomatic. Which makes me wonder if the this was the habit of the surgery to bill at a higher level.
What makes you a good expert for this case?
I have done 1000s of inguinal hernia repairs.
How often do you encounter cases similar to this one in your practice?
I have seen patient's with chronic pain after a bilateral inguinal hernia surgery. Normally, I do not recommend repairing both hernias at the same time. The recovery is longer and the complications can increase because of the "tight" space to place the mesh. Pediatrics is the one place a surgeon repairs a bilateral inguinal hernias even if they are asymptomatic.
Do you believe there might have been medical error?
In his operative report the surgeon confirmed there was no hernia on the left side but proceeded to place a mesh. The only indication to place a mesh is if there is a hernia. Placement of mesh caries a finite risk so if there is no indication to place a mesh, then the surgeon should not have placed one. I assume the mesh complications were on the left side where the inappropriate mesh placement was performed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Since there was no indication for a mesh and it resulted in complications then the error by the surgeon was a direct cause of the complication.
What makes you a good expert for this case?
Busy general and oncologic surgeon who performs many hernia repairs both open, robotic and laparoscopic. Also have 25 years of experience as a forensic expert and review about 6 cases a year.
How often do you encounter cases similar to this one in your practice?
30 to 40 times a year. Prior to 2019 I would perform over 100 hernia repairs a year.
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