Complications from hernia repair procedure
A 35-year-old man came to the ED reporting right lower abdominal pain following exercise.
by Olga Maystruk, Designer and Brand Strategist, and
Susie Edwards, Risk Management Representative
Presentation
On June 25, a 35-year-old man came to an emergency department (ED) reporting right lower abdominal pain following exercise. The patient had a history of hypothyroidism and gastric sleeve surgery.
Physician action
The ED physician saw the patient and ordered an unenhanced CT scan of the abdomen and pelvis; no pathology was observed. The ED physician suspected an inguinal hernia and referred the patient to General Surgeon A for a same day follow up. During the visit, General Surgeon A observed reducible inguinal hernias bilaterally.
On June 27, General Surgeon A surgically repaired the bilateral hernias with mesh via a laparoscopic incision. The treating anesthesiologist administered two postoperative bilateral transversus abdominis plane (TAP) blocks with ultrasound guidance.
Following surgery, the patient reported numbness and weakness in his right leg and left thigh. He was seen by a neurologist who ordered nerve conduction velocity (NCV) and electromyography (EMG) tests. After observing signs of femoral neuropathy, the neurologist ordered an MRI.
The scans revealed acute L5-S1 central disk herniation with inferior annular tear and moderate central canal stenosis. Additionally, an MRI of the pelvis with and without contrast revealed edema and enhancement of the right femoral nerve and some of the extending branches. The neurologist also observed enhancing loculated fluid, consistent with inflammation associated with inguinal hernia, along the anterior abdominal wall extending into both inguinal regions.
On July 15, General Surgeon A took the patient back to surgery to remove the mesh from the right inguinal area. He also referred the patient to a neurosurgeon.
On September 15, the patient saw the neurosurgeon and discussed a nerve repair procedure.
On November 10, the neurologist performed another NCV, EMG, and MRI and observed that a substantial right femoral nerve dysfunction still existed. A week later, a neurography MRI was performed that revealed tethering of the femoral nerve and atrophy of the anterior compartment muscles in the right thigh.
On December 5, the patient was evaluated by a plastic surgeon who recommended a femoral nerve graft using bilateral sural nerves harvested from the patient’s legs.
Two months later, General Surgeon B took the patient to surgery, exposed the pelvis and inguinal area, and removed some remaining mesh. The plastic surgeon then performed the nerve anastomoses. General Surgeon B performed the closure.
The patient was discharged nine weeks later, after starting physical and occupational therapy.
The patient still reports weakness, sensation insensitivity, and pain. He is taking pregabalin, oxycodone, acetaminophen, and topiramate.
Allegations
A lawsuit was filed against General Surgeon A and the anesthesiologist alleging the following:
- failure to obtain adequate informed consent;
- improper performance of the hernia repair;
- inappropriate order of a TAP block;
- failure to obtain an informed consent for the TAP block;
- failure to assess postoperative complications; and
- failure to perform an adequate mesh removal procedure (during July 15 surgery).
Legal implications
Consulting physicians who reviewed the case for the defense were critical of General Surgeon A’s informed consent discussion, as the patient was not told about potential complications or alternative treatments. While acknowledging that complications often occur during surgery, these consultants found General Surgeon A’s hernia repair performance deviated from the standard of care. However, they did note that the follow-up care was timely and appropriate.
One of the experts also stated that the patient may have an ambulatory disability and neuropathic pain for the foreseeable future. This may be difficult for the defense to overcome.
The plaintiff’s attorney consulted with the plastic surgeon in this case who reported that during surgery repair, he discovered “clear evidence” that the femoral nerve had been completely transected during the initial surgery performed by General Surgeon A.
A general surgeon who consulted with the plaintiff’s attorney believed that General Surgeon A was negligent in his performance of the laparoscopic hernia repair. He also stated that injury to the right femoral nerve could not have occurred during this procedure unless the surgeon was negligent.
Disposition
The case was settled on behalf of General Surgeon A. The outcome of the case against the anesthesiologist is unknown.
More on improper performance.
Risk management for general surgeons.
Risk management for anesthesiologists.
Disclaimer
This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physicians and the patient.
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