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The one and only

01 May 2010

Mr H, a 20-year-old sports student, presented to his GP complaining of an intermittent left groin swelling and pain in the same area when exercising. On examination, the GP noted a reducible swelling in the left groin consistent with an indirect inguinal hernia. He referred Mr H to the general surgery department of his local hospital, where Mr H was seen four weeks later by doctor in training, Dr T.

Dr T obtained Mr H’s medical history, which included a right orchiectomy following delayed presentation of testicular torsion as a 12-year-old; and subsequent insertion of a testicular prosthesis when aged 17. He examined Mr H, confirmed the clinical diagnosis of indirect left inguinal hernia and listed him for open mesh hernia repair. Operating a pooled waiting list for this procedure, Mr H was admitted four weeks later as a day case, under the care of consultant urologist Mr P, and underwent the above procedure. The operation was uneventful, as was his postoperative recovery.

Fifteen years later, Mr H consulted his GP together with his wife, as they had been unable to conceive in the preceding 18 months. The GP arranged a semen analysis, which was reported as showing azoospermia. He was referred to Mr P, who confirmed azoospermia on a repeat sample. He arranged a MESA (microsurgical epididymal sperm aspiration) and vasography, the latter showing obstruction of the vas at the level of the inguinal canal. An attempted reconstruction with vasovasostomy was unsuccessful, but Mrs H gave birth to healthy twins following a cycle of IVF, using a donor, 18 months after the initial referral.

Mr H made a claim against Mr P for failing to warn him of the risk of infertility during the consent and failure to take appropriate care during the operation.

Expert opinion

The experts took the view that on the balance of probability, the damage to the vas was either caused by fibrosis following surgery or by direct damage due to careless surgery. The case was eventually settled for a moderate sum.

Learning points

  • Careful attention to a patient’s past medical history might shed light on the presurgical situation.
  • When operating on the only remaining organ of a pair, extra care must be taken during the consent process and during the operation itself; in these circumstances, usually less significant complications can have devastating consequences for the patient.
  • It is important to have clearly documented the risks involved and the extra care taken during the operation.
  • Damage to the vas and damage to the testicular artery can occur after inguinal hernia repair, the latter potentially leading to even more serious consequences (reported incidences vary greatly, around 1% and 0.6% respectively following surgery in adults, and 2% and 2% respectively
    following surgery in children).
  • In these circumstances, it is good practice to add a warning note to the waiting list entry, so that a comment appears on the theatre list alerting the operating surgeon to the fact that surgery is to be performed on a single organ.
  • This case reflects the importance of occurrence-based indemnity, as claims can be made many years after treatment has taken place.