Infarction of the testis

A patient in his mid-50s with an inguinal hernia was referred by his GP to a general surgeon member of the MDU. He chose to have an open repair under local anaesthetic. He was otherwise well and had had a vasectomy.

The surgeon advised the patient of the risks associated with the procedure, including DVT, pulmonary embolism, bleeding, wound infection, acute retention of urine, bruising and a 1% risk of recurrence, and the patient signed the consent form.

At operation the patient was found to have a sliding indirect hernia. The surgeon repaired it using a mesh which was fishtailed to allow transit of the cord structures, and the sac was excised. The testicle was not mobilised from the scrotum. There was no immediate post-operative bleeding and the patient was discharged home the following morning.

By the evening the patient had developed pain in his wound. The next day he was seen by the surgeon who injected local anaesthetic into the medial part of the wound. This appeared to completely relieve the pain. The surgeon advised that if the injection failed to provide long-term relief then the wound would need to be explored to ensure that there was no nerve entrapment. 

The improvement proved short-lived, the pain returned and the patient was admitted for exploration of the repair under general anaesthetic. 

At operation there was no evidence of nerve entrapment or haematoma. The patient was discharged home on gabapentin for the pain. 

Three months later the patient returned reporting a large swelling of the scrotum. As this had subsided, he had found the testis had shrunk to half its original size. He had no further acute pain. An ultrasound scan showed an infarction of the testis due to ischaemia. 

Three years later the patient instructed solicitors who issued court proceedings alleging that the surgeon had been negligent and did not exercise reasonable care in performing the surgery. It was alleged that the hernia repair had been carried out in such a way as to cause tension in the wound, which was the cause of the testicular atrophy. It was not, however, alleged that the claimant should have been warned of the less than 1% risk of testicular atrophy.

At operation there was no evidence of nerve entrapment or haematoma. The patient was discharged home on gabapentin for the pain.

The MDU's expert agreed that it was not a breach of duty to fail to warn of this complication when performing a primary repair as the incidence of testicular atrophy is so low. However, if the patient had had a scrotal hernia or a recurrent hernia then this would be a different matter as the incidence is higher.

The MDU expert concluded that although the cause of the post-operative pain was hard to explain, it was likely that the testicular atrophy was due to ischaemia caused either at the first operation or at the re-exploration. This is well recorded following simple hernia repairs when minimal mobilisation of the spermatic cord has been undertaken. Other causes are when a large haematoma compresses the cord or the mesh is closed too tightly around the spermatic cord as it emerges from the deep ring. This can lead to venous engorgement and strangulation of the whole cord, but it was extremely unlikely that either of these was the case here. 

The expert concluded that just handling the cord, without any direct damage to the testicular artery, can lead to spasm of the artery and ischaemic atrophy. There is a very good collateral blood supply to the testis and under normal circumstances the testis should have remained viable even if the artery had gone in to spasm. The expert commented that in this case the previous vasectomy may have damaged the collateral blood supply, making the testicle more prone to ischaemic damage with spasm from the testicular artery. There was no reason to believe that the member had acted in any way below the expected standard. 

The MDU solicitor informed the claimant's solicitor that the case would be fully defended and that there was no evidence of any negligence. The claimant's solicitor was persuaded that his client's claim would fail and proceedings were discontinued.

Dr Glynis Parker
Senior medical claims handler

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