Testicular Atrophy Following Inguinal Hernia Repair
The most likely cause of testicular atrophy following open mesh inguinal hernia repair is thrombosis of the pampiniform plexus (Option C), which results from venous congestion and subsequent ischemic injury to the testis. 1
Pathophysiology of Post-Herniorrhaphy Testicular Atrophy
Testicular atrophy is an uncommon but well-recognized complication of inguinal hernia repair that frequently results in litigation. 1 The mechanism involves:
Venous thrombosis is the primary pathway, where surgical manipulation causes thrombosis of the pampiniform plexus (the venous drainage system of the testis), leading to venous congestion, testicular edema, and progressive ischemic atrophy. 1
Arterial injury (Option A - ligation of testicular artery) is actually less common as the sole cause because the testis has dual arterial supply from both the testicular artery and the cremasteric/deferential arteries, providing collateral circulation. 1
The testicular blood supply is relatively resilient to isolated arterial injury, but venous obstruction causes backpressure that cannot be compensated, making thrombosis of the pampiniform plexus the more common mechanism. 1
Risk Factors and Clinical Context
Identifiable risk factors are present in the majority of testicular atrophy cases following hernia repair: 1
Overzealous dissection of the distal hernia sac, particularly when the sac extends into the scrotum, increases risk of vascular injury. 1
Dislocation of the testis from the scrotum into the surgical wound during the procedure. 1
Concomitant scrotal surgery performed at the time of hernia repair. 1
Previous groin or scrotal surgery significantly increases the risk due to altered anatomy and scarring. 1
Why Other Options Are Less Likely
Option B (Mesh migration to scrotum): While mesh-related complications can occur, mesh migration does not directly cause testicular atrophy. Studies demonstrate that polypropylene mesh does not cause clinically significant effects on testicular blood flow or immunologic response. 2 Mesh complications typically manifest as infection, chronic pain, or mesh erosion rather than testicular size reduction. 3
Option D (Tightening of external inguinal ring): While excessive tension at the external ring could theoretically compress structures, this would more likely cause chronic pain or discomfort rather than progressive testicular atrophy. 1
Clinical Evidence
Research demonstrates that testicular complications following hernia repair are related to vascular compromise: 2
Doppler ultrasound studies show that resistive index (RI) and pulsatile index (PI) values temporarily change after hernia surgery, reflecting alterations in testicular blood flow. 2
In incarcerated hernia repairs, these flow parameters show significant differences but typically return to reference ranges, suggesting that venous thrombosis rather than permanent arterial injury is the mechanism when atrophy occurs. 2
The incidence of testicular atrophy ranges from 1.5% to 4.6% in various surgical series, confirming it as an uncommon but recognized complication. 4, 5
Prevention Strategies
Surgeons should implement these measures to minimize risk: 1
Careful preoperative assessment including detailed inquiry about previous groin or scrotal surgery. 1
Informed consent warning patients of increased risk when risk factors are present. 1
Gentle surgical technique avoiding overzealous dissection of distal hernia sacs. 1
Maintaining testicular position in the scrotum throughout the procedure. 1
Avoiding concomitant scrotal procedures when possible. 1