An inguinal hernia is a bulge of tissues such as part of the intestine that protrudes through the lower abdominal wall. It is estimated that 96% of all groin hernias are inguinal. They can occur on either side of the two passages in the lower abdominal wall, which are called the inguinal canals.
This blog will discuss in deep about inguinal hernia, repair and testicular torsion- a serious injury associated with inguinal hernia surgery. Testicular torsion has been associated with many medical negligence claims in the United States.
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In some cases, inguinal hernias also occur in the deeper passages in the groin called femoral canals. Hernia protruding in these canals is called a femoral hernia.
When an inguinal hernia occurs, a sac is formed around the hernia by a part of the peritoneum. Inguinal hernias can slide in and out of the abdominal walls. It mostly occurs on the right side of the groin compared to the left side. Studies indicate that individuals who develop inguinal hernia on one side are likely to develop on the other side too.
Risk Factors of Inguinal Hernia
An inguinal hernia may arise at any time between infanthood and adulthood. Research studies indicate that inguinal hernia is more likely to arise in males (27%) than females (3%).
The common risk factors are listed below.
- Age: Adults between the ages of 75 to 80 and children between the ages of 0 to 5 are highly prone to inguinal hernia.
- Weaker connective tissues
- Genetic factors
- Family history
- Prior abdominal surgery
- Increased pressure in the abdomen walls due to health conditions like chronic cough and constipation
- Excessive pressure in the abdomen walls due to standing for a long time or lifting heavy weights, or walking for hours
- Inguinal hernia is more common in premature infants when the lining of the abdomen does not fully close during their development.
- In some cases, pregnancy is found to be a cause of inguinal hernia due to the excessive pressure on the abdomen that weakens the muscles.
Symptoms of Inguinal Hernia
Although the symptoms may vary between individuals, the following are the common inguinal hernia symptoms.
- A bulge on either side of the pubic bone area becomes more apparent when the individual is upright, particularly during a cough or strain
- A sensation of pain or burning in the bulge
- Discomfort and a sensation of heaviness in the groin
- Pain and weakness in the groin, especially when bending over, coughing, or lifting weights
- Pain and swelling around the scrotum
Types of Inguinal Hernia
Indirect Inguinal Hernia
In a growing fetus, the inguinal canals have openings that are supposed to close before the birth of the infant. When the inguinal canal does not fully close by the time the baby is born, it causes weakness in the abdominal wall.
A piece of fat or intestine may slip through the abdominal wall causing an indirect inguinal hernia. It is more common in male fetuses. Premature infants are at higher risk for this type of hernia since there is less time for the closure of the inguinal canal.
In women, the female organs or the small intestine slide into the groin through a weakness in the abdominal wall, causing an indirect inguinal hernia.
Direct Inguinal Hernia
It is the most common inguinal hernia. The contents of the abdomen bulge out through the weaker muscles in the lower abdomen wall developing a hernia. This type of hernia is mostly seen in men than women and children.
Incarcerated Inguinal Hernia
Incarcerated inguinal hernia is developed when the herniated tissue gets trapped in the groin or scrotum and cannot be pushed back to its place by massage. This condition can lead to bowel obstruction or strangulation.
Incarcerated external hernias are reported to be the second most common cause of small-intestinal obstructions. It contributes to about 5-15 % of all operated hernias.
Strangulated Inguinal Hernia
After the fatty tissue or a portion of the small intestine pushes through the weakened abdominal wall, the surrounding muscles are loosened around the tissue. This obstructs the blood flow to the intestine, which may even end up in a life-threatening situation.
Strangulated inguinal hernia is often found to be associated with incarcerated inguinal hernia or may also be present at birth.
Complications of Inguinal Hernia
The complication occurs when the contents of the hernia bulging through the abdominal wall cannot be massaged back inside the abdominal wall. When a hernia causes strangulation of the intestinal tissues, it can even lead to the death of the patient. When left untreated, inguinal hernias may enlarge. In men, this could extend into the scrotum, causing severe pain and swelling.
Diagnosis of Inguinal Hernia
The preliminary diagnosis of an inguinal hernia would be based on the medical records and physical examination of the patient. The physician would perform a physical examination of the abdomen, during which the patient is asked to cough, stand, or strain to identify the bulge caused by the hernia. Diagnosis is proceeded by massaging the bulge of the tissues to restore them to their original position.
Further diagnosis would be based on the reports of imaging studies of the abdomen like ultrasound scan, MRI scan, and CT scan.
Management of Inguinal Hernia
Watchful waiting is one suggestion given to inguinal hernia patients who don’t exhibit many symptoms or complications.
Muscle Strengthening Exercises
Exercises for inguinal hernia may be advised to patients with very mild symptoms. This may help to strengthen the abdominal muscles. These exercises may be suggested after an inguinal hernia surgery also. Since strenuous physical activity can trigger inguinal hernia, exercises should be approached with caution. Medical attention should be sought if the pain is felt while doing these exercises.
Surgery is another strategy followed in inguinal hernia treatment. Inguinal hernia surgery would be an open inguinal herniorrhaphy, a laparoscopic inguinal herniorrhaphy, or a robotic-assisted surgery. The type of inguinal hernia repair surgery would be based on the following criteria.
- Size of the hernia
- Type of the hernia
- Age and health condition of the patient
- Medical history of the patient
Open Inguinal Herniorrhaphy
In open inguinal hernia surgery, the patient is sedated with either general anesthesia or local anesthesia.
The surgeon first makes a single long incision in the groin. In a direct inguinal hernia, where the hernia is bulging out of the abdominal wall, it is pushed back into place. In the case of an indirect inguinal hernia, the hernia sac is either pushed back through the inguinal canal or tied off and removed.
In either case, after repairing the hernia, a synthetic mesh is stitched or glued to the weaker abdomen wall to close and to strengthen it. This prevents the reoccurrence of the hernia. Another method is the primary closure of the surgical site with sutures.
Laparoscopic Inguinal Herniorrhaphy
In laparoscopic surgery, the patient is sedated with general anesthesia. It is a minimally invasive procedure where the surgeon makes tiny, half-inch incisions or punctures in the lower abdomen. The laparoscope and the surgical tools are inserted into the intestine through the small cuts.
The hernia is repaired, and the weaker muscles are stitched with a synthetic mesh to reinforce the weakened abdominal wall.
Laparoscopic inguinal herniorrhaphy is less painful with speedy recovery when compared to open surgery.
Robotic-Assisted Inguinal Hernia Repair
Robotic laparoscopic surgery provides a high-definition, critical view of the surgical site. Seated at a console in the operating room, the surgeon directs the robotic arms and performs the surgery. Since the robotic instruments are flexible and wristed, making incisions and placing the mesh would be much more precise in a robotic-assisted hernia repair.
According to the U.S. Food and Drug Administration, hernia surgeries implanting surgical meshes are reported to have the following complications like pain, infection, mesh migration, etc.
Testicular Torsion After Inguinal Hernia Surgery
Testicular torsion is a urological emergency occurring due to the torsion of the spermatic cord structures. The spermatic cord supplies blood to the testicles, and the torsion to it interferes with testicular blood flow. Inadequate blood flow to the testicles gradually leads to the damage or even death of the testicles.
Sudden shooting pain in one side of the scrotum is the most common symptom of testicular torsion. When diagnosed at the right time, testicular torsion could be treated without permanent damage to the testicles. Color doppler ultrasonography is the commonly implied diagnostic imaging study used to study testicular torsion.
Though not common, testicular torsion after hernia surgery is reported in some cases where the synthetic surgical mesh is used. The spermatic cord may be damaged by prolonged inflammatory tissue remodeling after inguinal hernia surgery with synthetic mesh methods. The mesh repair procedure may induce an inflammatory response that leads to the enclosure of the spermatic cord by scar tissue. This may rarely block the blood supply, may cause acute scrotum, and end up in testicular complications after hernia surgery. However, testicular ischemia caused by testicular torsion after hernia surgery with synthetic polypropylene mesh is a significantly more uncommon complication.
Some men may experience swollen scrotum after inguinal hernia surgery and a black and blue scrotum. This is typical, however, it can get worse after a few days. Use cold packs and use supportive undergarments like briefs to help minimize swelling. In a few weeks, the scrotum will get back to normal.
It is very important to note that testicular pain after hernia surgery may also be the result of a mesh-independent testicular torsion. This is also reported in some patients post inguinal hernia surgery. In such cases, there is a chance for the hernia mesh to be misinterpreted as the cause of testicular torsion.
Case Study of Inguinal Surgery Complication
A 60-year-old male was diagnosed with a right inguinal hernia. A general surgeon performed robotic-assisted laparoscopic right inguinal hernia repair. During the procedure, the inferior epigastric vessels were displaced anteriorly. The overlying peritoneum was taken down anteriorly, and the vessel was inadvertently transected.
Four days later, the patient visited the general surgeon with complaints of pain and swelling in the groin. The patient’s physical examination revealed extensive ecchymosis from right to left and into the scrotum. Scrotum was purple, as well as an exhibited hematoma in the cord. General Surgeon refilled the pain medication and advised the patient to follow up in a month.
On the following day, the patient’s spouse called the doctor’s office with the patient’s complaints of pain, difficulty walking, and his testicles were black.
The next day, the patient was taken to the emergency room with continuing testicle pain after hernia repair surgery. Ultrasound showed no blood flow to the right testicle, and the emergency physician diagnosed the patient with right testicular torsion and testicular infarction. The emergency physician opined that the previous inguinal hernia repair with large third bard mesh had injured the epigastric vessels. The patient was subjected to right orchiectomy, which is the surgical removal of the testicle.
Subsequently, the patient was subjected to scrotal exploration, and an emergency right orchiectomy was done by another surgeon. Surgical findings indicated that it was not a testicular torsion after hernia surgery. However, pathology of the right testicle revealed infarction in the testis and epididymis. The testicular pain after the hernia repair surgery was misdiagnosed as testicular torsion due to the surgical mesh.
In the above case study, the patient had reported testicular complications after hernia surgery. The primary treating surgeon had accidentally cut down the patient’s inferior epigastric vessels during the laparoscopic inguinal hernia surgery.
When the patient reported pain in the testicles, as per the standard of care, the surgeon should have ordered a detailed diagnosis with a Color Doppler Ultrasonography. Instead, he just refilled the pain medication and asked the patient to follow up in one month. The issue was diagnosed by the physician when the patient was presented in the emergency room. Ultimately it ended up in orchiectomy.
The medical negligence of the general surgeon during the hernia surgery and the failure to diagnose the complication on time caused medical complications in the patient. This resulted in the loss of the testicle from hernia surgery.
Medical error, which happened during the surgery, and the negligence caused in the timely diagnosis of the complication is evidently medical malpractice.
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Lawsuits for Testicular Torsion After Hernia Surgery
No surgical procedure is risk-free, and the same applies to inguinal hernia repair surgery. Testicle damage, pain, and torsion are some of the complications reported in hernia repair procedures. Though not common, testicular torsion is one of the acceptable complications of hernia surgery. Like other surgical procedures, there is a fine line between the anticipated surgery complication and negligence of the surgeon resulting in testicular torsion.
Is it possible for the patient to file a lawsuit for testicular torsion following inguinal hernia surgery?
Yes. If the patient encounters testicular pain after hernia repair, which is proved to be the result of testicular torsion, there is a chance for a medical negligence lawsuit. The claimant should substantiate that the torsion had occurred as a complication of the hernia repair surgery and was not a preexisting one. This is very crucial as testicular torsion is found to occur naturally in some individuals.
Medical records of the claimant could effectively reflect the medical history and the complications he had encountered as a result of the surgery. By conducting a thorough medical record review, it could be proved that testicular torsion had occurred post- hernia surgery.
Though not common, the chances of testicular torsion should be discussed by the physician before conducting the hernia surgery. Indication of the discussion in the informed consent form could help the physician from any medical malpractice lawsuit.
Detailed investigation and diagnosis should be conducted by the surgeon when the patient reports any testicular pain or discomfort after the hernia surgery. A timely diagnosis could identify if the torsion is mesh-related or not. Identifying and addressing the issue without delay would prevent permanent damage to the testicles.
A patient who becomes a victim of such medical errors could make a potential claim for medical malpractice. An experienced medical malpractice attorney could help the victim to pursue the lawsuit. The medical records of the plaintiff would act as concrete evidence in such cases. The medical chart would contain the data regarding the symptoms and complications of the patient, the diagnosis done, and the medications prescribed.
Offshoring the medical chart review process to an expert medical record review company would result in precise medical chart reviews to support the lawsuit. At LezDo techmed, we have skilled medical record reviewers and legal nurse consultants who can easily identify the strength and weaknesses of the medical chart within no time. We have played a major role in the success of many complicated medical malpractice claims by digging out crucial medical evidence.
When testicular torsion is not treated for several hours, blocked blood flow can cause permanent damage to the testicle. If the testicle is badly damaged, it has to be surgically removed. The pain can get worse or ease a bit, but probably won’t go away completely. Congrats for sharing this. I value and respect your opinion.
Men may experience pain in their testicle torsion on the side of the hernia repair, which may begin a few days after the operation and usually resolves within 48 hours. You’re coming up with creative solutions!
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Testicular ischemia is a rare complication of inguinal hernia repair. Testicular atrophy is an uncommon but well recognized complication of inguinal hernia repair and one that frequently results in litigation. Apart from the postsurgical etiology, ischemic orchitis and subsequent testicular atrophy may occur secondary to compression of the testicular vessels by chronically incarcerated hernias. This blog clearly explains about testicular torsion after hernia surgery. Most of the people not aware of this, Thank you very much for this wonderful blog.
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Hello all, I just had a robotic assisted inguinal hernia repair operation just over 2 weeks ago and had immediate right testicular pain. I called the doctor and he prescribed more pain meds and made my post surgery follow up appointment.
At the appointment he he checked my scrotum and told me this was normal and the pain will go away.
The pain has lessened but as not gone away and makes day to day activities hard to accomplish.
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