1. MANAGEMENT OF TESTICULAR ISCHAEMIA FOLLOWING AN INGUINAL HERNIA REPAIR
Taimur T Shah, Tim Davies, Evangelos Mazaris and Tom McNicholas
Department of Urology, Lister Hospital, Stevenage, UK
Introduction and Aim
Inguinal hernia repair is a common general surgical operation with 76,484 operations being performed in the United Kingdom during with over 90% being performed in males at an average age of 57.5 years 1. 70,166 were for a primary hernia repair whilst 6318 were for recurrent hernias. An inguinal hernia caries a lifetime incidence of 11 per 10,000 in the yr age group rising to 200 per 10,000 in over 75s.
Two common methods for repair are the Lichtenstein open mesh repair and the laparoscopic hernia repair.
Post operative urological complications make up to 12% of all complications. Scrotal complications include acute or chronic testicular neuralgia (1.5%), hydrocoeles (0.9%), haematocoeles (0.9%) and ischaemic orchitis and testicular infarction (0.5-5%).
Ischaemic orchitis is a devastating complication with an incidence of between 0.5 – 1 %, rising to 5% in recurrent hernia repairs. A greater incidence is seen when extensive dissection of the sac and cord has been performed particularly with dissection occurring beyond the pubic tubercle or dissection of distal indirect hernia sacs from the cord. Scrotal haematoma formation and mobilisation of the testicle are also a risk factors and in recurrent hernias avoiding dissection of the spermatic cord altogether by employing a posterior pre-peritoneal approach reduces the risk of ischaemia.
Patients presenting with acute or chronic testicular pain or swelling post-hernia repair are commonly referred to the urology department. A case series and a review of the available literature is outlined to create a guideline on best management for these patients with a view to preventing testicular atrophy and/or pain secondary to ischaemia.
Results
N = 27 Cases
Average Age
48.6 years
Open Repair
89%
24/27
Laparoscopic Repair
11%
3/27
Pain/Swelling < 1 week post op
Asymptomatic < 1 week post op
Colour Doppler US
[Fig 1]
56%
15/27
Hypo-echoic or Hypo-vascular testicle
Fig 2 (Above)
From the 27 cases of testicular atrophy/ischaemia 89% presented with acute onset of testicular pain either immediately post-operatively or within 1 week.
When a colour doppler ultrasound was performed it was diagnostic in all cases showing a hypoechoic and/or hypovascular testicle
Management at Referral
Conservative
56 % (15/27)
Scrotal Exploration
44% (12/27)
Further Management
1 Elective Orchidectomy
1 Hydrocoele repair only
6 Orchidectomy
1 open and close -atrophic
1 Orchidopexy
1 Haematoma evacuation only
2 Loosening/removal of mesh with salvaging of testicle
1 Division of adhesions around cord with salvaging of testicle
Method
Using the search query ((Ischaemia OR Infarct OR Infarction OR Ischaemic OR Ischemia OR Ischemia OR Torsion)) AND (((Testicle OR Testicular OR scrotum OR Scrotal)) AND (Inguinal OR Hernia)) we searched PUBMED, MEDLINE, CENTRAL and Cochrane (with no time period specified). 330 articles were identified. Abstracts and subsequently full articles were hand picked to leave 6 studies in which the management of patients with testicular ischaemia was detailed 2, 3-7. A further search of UK medico-legal societies (Medical Defence Union, MDU and Medical Protection Society, MPS) revealed 1 additional case 8.
We also searched through our hospital databases from and identified 6 further cases. A total of 27 cases were included in this compiled series.
Fig 3 (Above)
It appears from that literature that at acute onset of pain it may be possible to salvage an acutely ischaemic testicle by either loosening or removal of the mesh or by division of adhesions surrounding the cord
We thus propose a management algorithm (below)
Management Algorithm 
Fig 1a Left: Doppler USS, Spectacle view showing a hypo-echoic and hypo-vascular right testicle
Fig 1b Right: USS, Spectacle view showing a hypo-echoic and atrophic right testicle
References
1. DoH. Total procedures and interventions, HES online, 2009
2. Reid I, Devlin HB. Testicular atrophy as a consequence of inguinal hernia repair. Br J Surg 1994;81(1):91-3
3. Holloway BJ, Belcher HE, Letourneau JG, Kunberger LE. Scrotal sonography: a valuable tool in the evaluation of complications following inguinal hernia repair. J Clin Ultrasound 1998;26(7):341-4.
4. Pietro P, Francesco A. Testicular ischemia following mesh hernia repair and acute prostatitis. Indian J Urol 2007;23(3):323-5.
5. Moore JB, Hasenboehler EA. Orchiectomy as a result of ischemic orchitis after laparoscopic inguinal hernia repair: case report of a rare complication. Patient Saf Surg 2007;1(1):3.
6. Chu L, Averch TD, Jackman SV. Testicular infarction as a sequela of inguinal hernia repair. Can J Urol 2009;16(6):
7. Mincheff T, Bannister B, Zubel P. Focal testicular infarction from laparoscopic inguinal hernia repair. JSLS 2002;6(3):211-3.
8. MDU MDU, UK. Testicular atrophy after hernia surgery, 2002.
Discussion and Conclusion
Aetiology: Venous injury, Compression, Overzealous dissection or diathermy, Testicular mobilisation
CDUS has high sensitivity and specificity for testicular ischaemia
Potentially reversible complication
Tends to present within 1 week of the initial surgery
Patient should make an informed decision regarding the pros and cons of re-operation/exploration