Cutting the risks in hernia repairs

Case history

Mr Black consulted Dr Cut in June 2011. Dr Cut obtained the history that Mr Black had been troubled by left groin pain for the past year, and an ultrasound ordered by his GP revealed an uncomplicated reducible indirect left inguinal hernia.

On examination, Dr Cut elicited a positive cough impulse in Mr Black’s left groin, but she was unable to palpate a hernia. Mr Black also complained of testicular pain, which Dr Cut believed could be due to spermatic cord compression at the deep inguinal ring.

Dr Cut explained to Mr Black that although the ultrasound confirmed the presence of a hernia, she could not be certain this was the cause of his left groin pain. However, Dr Cut advised she was reasonably sure that repairing the hernia would fix Mr Black's groin pain, although there was no guarantee of success.

Dr Cut discussed the risks associated with laparoscopic hernia repair which she listed as wound and mesh infection, nerve injury, and recurrence. Mr Black confirmed that he understood the risks and provided his consent for surgery.

At the surgery performed a couple of weeks later, a hernia of extraperitoneal fat was revealed coming through the deep inguinal ring and accompanying the spermatic cord. Dr Cut used mesh which she fixed in place with staples, and the peritoneum was closed over the mesh with staples.

Three weeks later, Mr Black was reviewed by Dr Cut and advised he was still experiencing left groin pain following the surgery. There was no sign of any recurrence of the left inguinal hernia. Dr Cut referred Mr Black for an ultrasound of his left groin, and no abnormalities were identified in the report.

Mr Black then saw a sports physician and physiotherapist. He was advised to work on his core strength in the hope that his symptoms would settle with the strengthening of his gluteal muscles.

Four months post-surgery, Mr Black was still complaining of diffused pain in the left groin area. He was referred for a CT scan and an MRI. The imaging showed ‘no cause for presentation’.

A year later, Mr Black’s groin pain was still present, and he underwent two further surgeries with a different surgeon.

Mr Black commenced proceedings against Dr Cut, alleging her management was negligent in that Dr Cut had failed to obtain informed consent. It was alleged that it was inappropriate for Dr Cut to recommend surgery, and that a conservative approach should have been taken. There were also allegations about the surgical technique used, with staples or clips placed in an area of risk of damage to nerves.

Discussion

Up to 10 per cent of men will develop an inguinal hernia. Many are asymptomatic, and many do not require repair. The risk of bowel obstruction, which forms the basis of most surgeons’ advice to recommend repair, is probably overstated. Two longitudinal studies of patients who were not operated upon showed that most patients eventually elect to have their hernia repaired because of ongoing discomfort, but obstruction was rare.

With the substantial decrease in hernia recurrence rates over the last two decades, the focus on surgical outcomes has shifted from recurrence rates to chronic pain and testicular injury. This case highlights the former.

The guidelines for the management of groin hernia published by the HerniaSurge group¹ report an incidence of 10-12 per cent clinically significant chronic pain decreasing over time. Debilitating chronic pain severe enough to affect daily activity and work has an incidence of 0.5-6 per cent.

In this case, the patient was in pain before his surgery and remained in pain after it. We do not know the patient’s expectations, but his surgeon told him she was confident his pain would be alleviated.

Pre-operative risk factors for pain include young age, female gender, pain elsewhere or in the groin, and mental status. Peri-operative risk factors include inexperienced surgeon, open technique, as well as mesh type and fixation. Post-operative factors include increased pain in the immediate post-operative period, post-operative complications, and sensory dysfunction.

The key message is beware the patient presenting with pain as the dominant symptom. Their expectations concerning pain relief are likely to be unrealistic.

Medico-legal issues

As for all surgical procedures, patients undergoing elective hernia repair should be advised about the risks, including chronic post-operative pain.

Good documentation of the consent discussion is vital in the event of a claim or complaint. You cannot rely on your recall of events to defend yourself. Some discussion of chronic pain, perhaps reflecting that the patient understands its consequences, must be documented.

Better still, be very cautious about recommending a hernia repair in a patient with an incidental hernia. You will successfully treat the hernia, but may be left with a very dissatisfied patient.

References

1. The HerniaSurge Group. International guidelines for groin hernia management. Hernia (2018) 22:1–165
   

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