VCUDeath and Complications Conference

Introduction for Every Case

Complication Testicular Artery Laceration,

Prophylactic Orchiectomy Procedure

Umbilical and Right Inguinal Hernia Repair

Primary Diagnosis Umbilical and Right Inguinal Hernia

66 yoM referred from his PCP for umbilical and right inguinal hernia which intermittently cause pain

PMH: Peripheral Neuropathy, Chronic LBP, Gout, Anxiety, Hemorrhoids, HTN, Hyperlipidemia, Obesity

PSH: None

Meds: Vicodin, Amlodipine, Rosuvastatin, Allopurinol, Niacin, Aspirin, Colchicine, Vitamin D, HCTZ, Metoprolol, Docusate

ALL: NSAIDs

PE: 97.1 53 154/90 BMI: 35.8 ABD- Soft, NTND, reducible umbilical

hernia ~3cm defect Groin- Reducible Right Inguinal Hernia

Umbilical hernia repaired with PHS

Incision, external oblique fascia was entered, tissue was thick and adherent and there was difficulty identifying the spermatic structures

The vas was identified proximally, but was adherent to a large hernia sac and fatty tissue distally.

On dissecting around the cord, an arterial bleed was encountered which was thought to be the testicular artery

At this point it was felt the testicle may become ischemic postoperatively and an orchiectomy was performed

The inguinal ligament was sutured to conjoined tendon, closing the inguinal ring completely and overlay mesh was placed

Analysis of Complication

• Was the complication potentially avoidable?– Yes. Technical Error

• Would avoiding the complication change the outcome for the patient?- Yes. Orchiectomy was unnecessary procedure

• What factors contributed the complication?– Pts obesity, failure identify key structures, technical

error

Bassini Hernia Repair

Lichtenstein Hernia Repair

JAMA 2006

Fitzgibbons et al

Fitzgibbons et al

Fitzgibbons et al

Fitzgibbons et al

1 Acute Hernia Incarceration occurred in two years in the watchful waiting group (0.3%)

The “Hernia Accident Rate” was 0.0018 events per patient year

By two years 23% of watchful waiting patients had crossed over to surgical repair (31% in 4 years)

Fitzgibbons et al

Conclusion: Watchful waiting is a safe and

acceptable option for men with assymptomatic or minimally symptomatic hernias

Acute hernia incarcerations occur rarely Patients who develop symptoms have no

greater risk of operative complications than those undergoing prophylactic repair

JLAST 2012

Slavin et al

Slavin et al

Slavin et al

Slavin et al

Slavin et al

Slavin et al

Slavin et al

The difference in reoperation rate was in the first two years and appears to affect patients operated on by low caseload laparoscopic surgeons

This study provides evidence of the need for an adequate caseload for surgeons undertaking laparosopic repair of inguinal hernia