48 year old male underwent open repair of large left inguinal hernia at ambulatory surgery center in 2007 performed by a general surgeon “specializing in minimally invasive surgical techniques.” Patient experienced post-op pain and sense of swelling in scrotum in PACU before same-day discharge. Wife called surgeon’s office next morning (1st post-op day) to report husband having worsening same complaints, but only instructed for him to come in for routine follow-up appointment on 9th post-op day. Patient taken to ER on 3rd post-op day with persistent scrotal pain, left side scrotal swelling and now difficulty urinating, but discharged with a larger scrotal support after ER physician called surgeon’s office. Patient taken back to surgeon’s office on 4th post-op day with persistent complaints, and after brief exam told to return on 9th post-op day as previously scheduled. Surgeon’s office called again on 5th post-op day, but patient only received a different prescription for pain called into a pharmacy for patient pickup. On 6th post-op day patient taken to different ER and admitted to hospital. Diagnosed with a strangulated left testicle and cord which were surgically removed on 8th post-op day. Operative report notes “a torsed and necrotic testicle and most likely due to arterial compromise as the external ring was quite narrow.”

Issue: Is there an actionable negligence claim against surgeon (or others) for the patient’s loss of a testicle? When did the testicle probably die, i.e., are there any causation obstacles?

EXPERT RESPONSES

Once the testicle loses blood supply, there is an eight hour window to do an operative intervention. That probably occurred the day of surgery. By the time the patient was in the ED on day three, the testicle was dead. Although the EP did not follow an accepted standard of care, the outcome would not have changed. There is little doubt in my mind that there is a strong case against the surgeon, but you will need a surgical expert as well. DR FM – ER

Loss of a testicle is a somewhat acceptable complication of hernia surgery and should have been mentioned in the informed consent discussion. But since it is a known complication, it should have been investigated during the several times he was seen before he went to the second emergency rm. Sometimes the pathologist can tell the age of the infarction so this could be pursued and might help with the timing of the tissue death. It could be argued that there was ischemia early on that more likely than not it could have been reversed had that diagnosis been entertained. These cases can be difficult but there is merit.I believe there is causation as well as negligence here. I would pursue it. DR MB – Urologist

Fascinating case. do not know how the pt developed torsion of the testicle- much more likely to be ischemic orchitis secondary to hernia repair. Everyone missed the boat but testicle was probably dead within 8-24 hours after complaints began, which appears to be in the recovery room. Not sure how easily you make a case out of this though clearly everyone missed the boat. DR JF – General Surgeon

To show causality, would need to review the op reports, diagnostic studies, ie. testicular ultrasound or nuc. med scan, and path report. It sounds like ischemia occured when the superficial (or deep) ring was closed to tight and it would have died 6-8 hrs following the surgery. A potential obstacle is the remote possibility of unrelated testicular torsion.

DR MJM – General Surgeon