2.  Complication  Testicular Artery Laceration, Prophylactic Orchiectomy  Procedure  Umbilical and Right Inguinal Hernia Repair  Primary Diagnosis  Umbilical and Right Inguinal Hernia

3.  66 yoM referred from his PCP for umbilical and right inguinal hernia which intermittently cause pain  PMH: Peripheral Neuropathy, Chronic LBP, Gout, Anxiety, Hemorrhoids, HTN, Hyperlipidemia, Obesity  PSH: None

4.  Meds: Vicodin, Amlodipine, Rosuvastatin, Allopurinol, Niacin, Aspirin, Colchicine, Vitamin D, HCTZ, Metoprolol, Docusate  ALL: NSAIDs

5.  PE: 97.1 53 154/90 BMI: 35.8  ABD- Soft, NTND, reducible umbilical hernia ~3cm defect  Groin- Reducible Right Inguinal Hernia

6.  Umbilical hernia repaired with PHS  Incision, external oblique fascia was entered, tissue was thick and adherent and there was difficulty identifying the spermatic structures  The vas was identified proximally, but was adherent to a large hernia sac and fatty tissue distally.

7.  On dissecting around the cord, an arterial bleed was encountered which was thought to be the testicular artery  At this point it was felt the testicle may become ischemic postoperatively and an orchiectomy was performed  The inguinal ligament was sutured to conjoined tendon, closing the inguinal ring completely and overlay mesh was placed

8. Was the complication potentially avoidable? – Yes. Technical Error Would avoiding the complication change the outcome for the patient? - Yes. Orchiectomy was unnecessary procedure What factors contributed the complication? – Pts obesity, failure identify key structures, technical error

15.  1 Acute Hernia Incarceration occurred in two years in the watchful waiting group (0.3%)  The “Hernia Accident Rate” was 0.0018 events per patient year  By two years 23% of watchful waiting patients had crossed over to surgical repair (31% in 4 years)

16.  Conclusion:  Watchful waiting is a safe and acceptable option for men with assymptomatic or minimally symptomatic hernias  Acute hernia incarcerations occur rarely  Patients who develop symptoms have no greater risk of operative complications than those undergoing prophylactic repair

24.  The difference in reoperation rate was in the first two years and appears to affect patients operated on by low caseload laparoscopic surgeons  This study provides evidence of the need for an adequate caseload for surgeons undertaking laparosopic repair of inguinal hernia