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Enmeshed in complications

01 May 2007

Mr D, a 51-year-old builder, noticed a lump in his groin. His GP diagnosed a hernia and referred him to a local general surgeon, Mr J, who found that Mr D had both femoral and inguinal herniae on the right side.

Mr J advised that Mr D have an open repair of his herniae with a nylon mesh. He used a leaflet that he had designed to explain the procedure and its potential complications to Mr D. Mr J documented that he had used the leaflet as part of his consenting procedure, and that he had explained possible significant complications of the procedure to Mr D.

A year after his surgery Mr D’s herniae appeared to have been effectively repaired, but he was troubled by a niggling and dragging sensation over the operation site. Mr D was anxious that something be done to resolve this problem so Mr J agreed to re-examine the repair and perform any remedial work that was necessary. Mr J documented that he had explained to Mr D that there was a significant risk that further surgery would make no difference to his pain and that he might find no reason on clinical examination for his discomfort.

Mr J performed further surgery but could find no significant problem with the hernia repair. There was a small section of mesh that was not firmly in place and so Mr J used staples to re-affix it. Despite this Mr D’s symptoms continued unabated and two years after his original operation he requested that Mr J perform further surgery to relieve his symptoms.

Mr J counselled Mr D that this would not necessarily improve the situation and documented this fact. He warned Mr D of the possible complications of further surgery in the area.

Mr J found that the original mesh that he had placed had rolled up at one edge, so he placed a larger mesh in-situ. Despite this Mr D continued to suffer pain in his groin and upper leg. He was referred by Mr J to a colleague who diagnosed femoral neuralgia secondary to hernia repair. Shortly after this Mr D launched a legal action against Mr J alleging that his surgical technique had been poor, necessitating re-operation and causing the complication of femoral neuralgia. Mr D’s claim stated that he was no longer able to work in the building trade due to the incapacity caused by his groin pain.

Expert opinion

An expert general surgeon could find no fault with any of Mr J’s operative interventions, techniques or clinical decisions. It was not felt that any of the surgical procedures were at fault or could be held to be responsible for the initial postoperative pain or the rare but accepted complication of femoral neuralgia. The expert was impressed with the quality of Mr J’s clinical and operative notes and felt that Mr D had been warned of possible complications and that Mr J could not be held to be negligent or to have caused Mr D’s postoperative complications. We defended the claim and it was discontinued shortly afterwards.

Learning points

  • This case was relatively easy to defend because Mr J had kept good clinical and operative notes and explicitly documented the information he had used to warn of complications of surgery.
  • Postoperative pain is a recognised complication of hernia repair and thought to be due to damage to relevant nerves or their smaller branches during the procedure.
  • Where a procedure has an appreciable incidence of a recognised complication such as this, then it is important that patients are aware of this before they consent to surgery and that this fact is clearly recorded in their clinical notes.
  • See the two recent papers above for current theories on the nature of postoperative neuralgic pain after hernia repair, and how this complication could possibly be avoided.

Further information

  1. Wijsmuller A et al., Nerve Management During Open Hernia Repair, Br J Surg; 94(1):17–22 (2007).
  2. Wijsmuller A et al., Nerve- Identifying Inguinal Hernia Repair: A Surgical Anatomical Study, World J Surg; 31(2):414-20 (2007).