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Review

The Impact of Social Media on Public Perception and Litigation in Hernia Surgery Complications: A Narrative Review

by
René Gordon Holzheimer
1,* and
Nadey Hakim
2,3,4,5
1
Hernia Surgery, Ludwig Maximilians University, 82064 Munich, Germany
2
Cleveland Clinic London, London SW1X 7HY, UK
3
General Surgery, Lerner College of Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
4
American College of Surgeons (UK Chapter), Chicago, IL 60611, USA
5
de l’Academie Francaise de Chirurgie, 75006 Paris, France
*
Author to whom correspondence should be addressed.
Complications 2024, 1(3), 51-60; https://doi.org/10.3390/complications1030009
Submission received: 9 July 2024 / Revised: 19 September 2024 / Accepted: 1 October 2024 / Published: 8 October 2024
Versions Notes

Abstract

:
Title: The Impact of Social Media on Public Perception and Litigation in Hernia Surgery Complications. Introduction: Social media significantly impacts public perception of healthcare, leading to increased litigation for complications after hernia surgery. Our research focused on terms like ‘inguinal hernia repair,’ ‘medico-legal,’ ‘informed consent,’ ‘litigation,’ ‘malpractice,’ ‘social media’, ‘mesh’, ‘Leistenbruch’, and OLG in Pubmed, Google Scholar, and Google. Results showed chronic postoperative pain as a common cause of malpractice claims, with ultrasound being a valuable diagnostic tool. Urological injuries account for a significant portion of complications after surgery. Mesh infection leads to hospital readmission, increased healthcare costs, and lawsuits. The quality of the consent process is crucial, and patient perceptions of mesh use influence their decision-making. Healthcare professionals must understand the impact of social media on public perception and provide comprehensive patient information for informed consent and satisfaction.

1. Introduction

Social media significantly shapes public perception of healthcare, leading to increased litigation for complications post-hernia surgery. In 2016, social media influenced FDA regulations on transvaginal mesh, emphasising public opinion’s impact on healthcare policies. This influence is evident in hernia surgery, with 36.5% of 1.1 million tweets expressing pessimism about using mesh. Notably, three of the top five tweeters on mesh for hernias have ties to lawyers involved in mesh litigation [1].
Insurance data from Finland showed that between 2003 and 2007, 55,000 inguinal herniotomies were performed, resulting in 250 patient claims and 92 patients receiving compensation. Severe complications were rarely reported during that time [2].
Knowledge of legal conditions and personal risk management may help avoid malpractice claims [3].

2. Material and Methods

We searched for relevant terms in inguinal hernia surgery and medico-legal issues. These terms included ‘inguinal hernia repair,’ ‘informed consent,’ ‘litigation,’ ‘damage claim,’ ‘malpractice’, ‘legal’, ‘social media’, ‘mesh’, ‘Leistenbruch’ (German for inguinal hernia), and OLG (German higher district court). This comprehensive search was conducted in reputable databases such as Pubmed, Google Scholar, and Google to ensure the inclusion of all relevant literature. We divided the narrative report into the following topics: pain, ultrasonic examination of complications, urological complications, infection, vascular injury, complications and damage claims, informed consent, recent procedures at German higher district courts, and mesh court procedures.

3. Pain

According to HerniaSurge Guidelines, the incidence of chronic pain is in a range of 10–12% [4].
The exact cause of pain after inguinal hernia surgery is often not known. An evidence-based treatment pathway is needed to address a significant problem in managing this complication [5].
Fifty percent of patients (n = 59) experienced chronic pain after a median of 62 months, with 30 percent (n = 30) reporting an impact on daily activities. The study found that doctors did not inform patients about the possibility of chronic pain during the informed consent process. Twenty percent of patients said they would not have chosen surgery if they had known about the potential for chronic pain. The study recommends mandatory documentation of information about chronic pain. Patients were sent a questionnaire, and non-responders were contacted by telephone. There was no percentage of doctors who failed to inform the patients [6].
Chronic pelvic and perineal pain has been the subject of numerous severe medical malpractice cases in France since the law of 4 March 2002 [7].
Accurate and detailed operative notes are essential for preventing legal disputes related to chronic groin pain after inguinal hernia surgery. In surgical reports, mentioning the identification and treatment of groin nerves is crucial. Understanding the anatomy of the inguinal nerve is vital for successful hernia repair, and dermatome mapping tests can help evaluate postoperative pain. Failure to identify nerves in the reports increases the likelihood of chronic pain [8].
Studies from specialised laparoscopic hernia centres suggest that pain is not a common issue, but this may not be universally true. Patients experiencing severe and persistent pain after laparoscopic inguinal hernia repair belong to specific subgroups that display signs of neuropathic, inflammatory, or mechanical irritation [9].
The understanding of chronic pain has improved since 2009, but not all authors agree. Surgeons are discussing the risk of chronic pain with more patients in 2019 compared to 2009. However, discussions mainly occur on the day of surgery, which may pose the risk of inaccuracies. This procedure is relevant to informed consent, especially after the 2015 Montgomery vs. Lanarkshire Health Board case, which changed how patient consent is viewed. Despite this, there has been no significant improvement in consent practices for chronic pain following the Montgomery ruling [10].
Montgomery sued for negligence, arguing that she would have requested a caesarean section if she had known of the increased risk. The Supreme Court of the UK announced a judgement in her favour in March 2015. It established that, rather than being a matter for clinical judgement to be assessed by professional medical opinion, a patient should be told whatever they want to know, not what the doctor thinks they should be told [11].
Opioids used to treat chronic pain may cause considerable morbidity and mortality. Deficits in clinical judgement, patients’ unwillingness to cooperate, and poor documentation are the causes of complaints [12].

4. Ultrasonic and Magnetic Resonance Imaging (MRI) Examination of Complication

Ultrasound (US) examination is a reliable tool for diagnosing chronic postoperative inguinal pain (CPIP). It can detect various issues such as effusion, testitis, limited movement of the spermatic cord, varicocele, and mesh-related problems [13].
US examination and haemoglobin measurement should be included in the patient examination if there is a clinical suspicion of a postoperative complication instead of just a routine exam [14].
Despite the high sensitivity and specificity of ultrasound examination, the results depend on the operator’s experience level [15].
The cause of pain may not be determined “straightforward” by ultrasound [16].
Clinical examination may be more relevant for surgical decision for operation [17].
Ultrasound-detected hernias (UDH) may not be the cause of pain in patients with groin pain [18].
Therefore, magnetic resonance imaging (MRI) and MRI neurography (MRIN) may be valuable tools for revealing the cause of pain [19].
However, the use of MRI to detect a specific cause of inguinal hernia repair-related pain has been doubted [20].

5. Urological Complications

Testicular atrophy is a rare complication of inguinal hernia repair and often leads to legal action. Surgeons should thoroughly review the patient’s history of inguinal or scrotal surgery and, if necessary, inform the patient about the heightened risk of testicular atrophy before the surgery. Aggressive dissection of a scrotal hernia sac could be detrimental [21].
Rare urological complications of inguinal hernia repair include microhematuria and bladder lesions [22].
In 2015, the Finnish Patient Insurance recorded 62 urological complications out of 92,000 inguinal hernia operations. These included 34 testicular injuries, 10 bladder perforations, seven cases of massive scrotal bleeding, and 11 other injuries. Factors such as hospital status, surgeon training level, type of surgery, type of hernia, or use of mesh did not correlate with testicular injuries. Urological injuries accounted for one-fifth of the significant complications after inguinal hernioplasty [23].
Inguinal hernia surgery without mesh has no impact on male fertility and obstructive azoospermia. The potential for infertility should be discussed when considering mesh in bilateral open and laparoscopic repairs [24].
However, male infertility may be prevented by risk screening and appropriate use of surgical technique [25].
Testicular ischemia and necrosis are rare complications following inguinal hernia repair. According to a report, there is no consensus in the literature regarding the mechanism of infarction and necrosis. Complete testicular ischemia and necrosis in the early phase after inguinal hernia repair using a mesh can lead to orchidectomy [26].
However, testicular atrophy may be due to thrombosis of the veins of the spermatic cord from surgical dissection in open and laparoscopic inguinal hernia repair rather than iatrogenic arterial injury [27,28].
The reported incidence rates of sexual dysfunction (SD)—completion of intercourse—and pain with sexual activity (PSA)—pain with erection/ejaculation—after inguinal hernia repair in males vary considerably. Sexual dysfunction is common after inguinal hernia repair and should be included in preoperative counselling [29].
Chronic genital pain, dysejaculation, and sexual dysfunction are occasionally reported. Patients experience pain during sexual activity, genital or ejaculatory pain, and pain that significantly affects their sexual function. Around 3% of younger male patients who have had inguinal hernia repair are impacted by these issues [30].
In total, 23% (n = 37) of patients reported experiencing pain during sexual activity before surgery. Sexual life was moderately to severely affected in 17% (n = 27) of the patients. After six months of hernia repair, 10% (n = 16) still experienced pain during sexual activity. Patients who had preoperative pain during sexual activity were at a higher risk of experiencing postoperative pain during sexual activity compared to patients without preoperative pain [31].

6. Infection

The debate continues regarding the effectiveness of antibiotic prophylaxis in hernia repair. There is a new discussion on whether antibiotic prophylaxis is necessary to prevent surgical site infections, especially with the introduction of mesh-based herniotomy and studies showing high wound infection rates. While antibiotic prophylaxis seems to have little effect in low-risk infection settings, in a high-risk setting, it may reduce the risk of surgical infections [32].
Surgical mesh infections can result in higher healthcare costs, additional hospital visits, surgeries, hernia recurrence, reduced quality of life, and legal problems. Factors like obesity, smoking, and diabetes are closely linked to wound infections after hernia surgery. Managing these before surgery is crucial. The type and placement of the mesh, the patient’s smoking habits, the presence of certain bacteria, bacterial adhesion, and biofilm formation affect the risk of mesh infection. The usefulness of suction drains in hernia repair may not be evident. A surgical risk calculator can help forecast complications and outcomes for individual patients [33,34,35,36].

7. Vascular Injury

In most common types of inguinal hernia repair, the stitches are placed superficially to the internal iliac artery and vein or through their sheath. The artery is at risk if the sutures include the fascia transversalis to close the medial part of the internal inguinal ring. Injuries can occur due to accidental damage to the artery or its branches. Immediate repair is necessary for an arterial injury. Abnormal pulses near the inguinal injury are not acceptable. Sufficient exposure is crucial, and transection of the inguinal canal floor may be needed. Repair might involve a simple hemostatic suture, patch graft, or interposition graft [37].
Femoral vein stenosis may develop after a McVay hernioplasty. Accidental injury during hernia repair can result in femoral vein stenosis and lead to thromboembolism [38].

8. Complications and Damage Claims

The Finnish National Patient Insurance Association found that out of 55,000 inguinal hernia surgeries, there were 115 severe and 135 moderate complications, resulting in an overall complication rate of 4.5 per 1000 procedures. A total of 38% of patients received financial compensation. The report also revealed an association between chronic pain and general anaesthesia, surgery duration, and wound complications. Paajanen et al. (2010) divided complications into moderate (n = 135) and significant (unreasonable) (n = 115) complications. Moderate complications were superficial infections or haemorrhages, mild or moderate postoperative pain or numbness, and early recurrence (usually because of technical failures). Major complications were injuries to the intestine, urinary bladder, testes, or large vessels requiring additional surgical procedures, severe neuropathic pain resulting in referral to a pain clinic, and deep mesh infections [39].
Litigation resulting from surgical procedures since 1995 has led to over £1.3 billion, $2.1 billion, or €1.4 billion in financial claims for the National Health Service (NHS). Testicular injuries and chronic pain were present in 40% of claims following hernia repair. Successful claims were predicted by visceral injuries and injuries requiring corrective procedures. Laparoscopic procedures saw more claims related to visceral and vascular injuries compared to open procedures. To minimise litigation and enhance patient care, measures should be pursued to reduce visceral and vascular injuries, particularly during laparoscopic repair [40].
In 2013, Walters et al. highlighted the harms associated with hernia repair surgeries, including infection, death, and other issues. They reported a case where a patient sued a surgeon for not using mesh during surgery, as detailed in the informed consent form. The court ruled in favour of the plaintiff in 27% of similar cases, awarding damages from $19,000 to $8,000,000. To avoid lawsuits, it was recommended to focus on patient education, thorough documentation, and adherence to standard surgical practices [41].
The Finnish Patient Insurance Centre (FPIC) recorded data from 2002 to 2010 on inguinal hernia repairs in Finland. Over 75% of these repairs used open mesh (OM) hernioplasties. Complication reports indicated more severe complications after laparoscopic (LAP) and open suture (OS) repairs compared to open mesh (OM) operations [42].
In the Swedish healthcare system, claims from patients with health-related injuries or medical malpractice are handled by a mutual insurance company called LÖF. The Swedish Hernia Register (SHR) records about 98% of all Swedish hernia operations. Out of 130 claims received by LÖF, 26 cases involved bleeding, 20 testicular injuries, and seven intestinal lesions. A total of 62% of the complications were due to medical malpractice under the Swedish Patient Injury Act. Some risk factors for claiming damages included acute and recurrent surgery, suture repair, and general anaesthesia, with women filing claims more frequently than men [43].
In 2018, Grayson and colleagues reviewed 25 years of litigation patterns in inguinal hernia repair. Verdicts favoured the defendant 67% of the time, with an average plaintiff award of $1.21 million. The most common legal arguments were improper performance and failure to comply with informed consent. Nerve/chronic pain and testicular damage were significant complications. Case outcomes did not correlate with patient gender, age, surgical approach, or mortality. Only 21.7% of cases favoured the plaintiff, with an additional 10.9% resulting in settlements [44].
In France, between 2010 and 2016, 209 medical liability insurance cases were reported, of which 180 were assessed. The Conciliation and Compensation Commission (82 patients) and the Supreme Court (79 patients) reported the decisions. Claims of damage in inguinal hernia repair cases were linked to chronic pain, infection, and testicular damage. Surgical errors, infections, delays in reoperation, and the operating room environment were identified as causal factors for the damage [45].
Inguinal hernia mesh repair is linked to the potential for mesh-related visceral complications (MRVCs). The highest incidence is associated with laparoscopic hernia repair, while the lowest is related to the Lichtenstein technique. Bladder involvement mainly occurred after laparoscopic hernia repair. Treatment typically involves removing the infected tissue and repairing or removing the affected organs [46].
Varley et al. reported 880 claims and 760 settlements in the UK in 2020. The most common reasons for claims were visceral/vascular injuries in the laparoscopic group and testicular complications or chronic pain in the open group. Additional procedures were required in 48% of laparoscopic and 44% of open claims, leading to increased payouts. Clinical negligence litigation for inguinal hernia repair in the UK is rising, with an increase in laparoscopic claims recently noted [47].
In certain instances of complications and well-defined situations, a comprehensive assessment should persuade any surgeon to choose a conservative approach and refrain from promptly opting for surgical treatment, particularly in elderly, high-risk patients with long-standing abdominal wall hernias [48].
Treatment strategies and management of postoperative complications depend on the individual situation in surgical site infection, recurrence, postoperative pain, and mesh-induced complications. Risk factors, diagnostics, and treatment modalities are given by Lu et al. (2021) [49].
Sweden has a “no-fault patient injury compensation plan” financed by a tax system. This plan compensates patients for damage related to hospitalisation or medical treatment. In contrast to the tort liability system, proof of wrongdoing is not necessary. The system was changed in 1975 because only a few patients received compensation in the old system. The new system has been suggested as a model for the US [50].
A malpractice crisis in the US led to proposals (2004) to reform the tort malpractice system, including a no-fault compensation system or a hybrid system combining no-fault and tort systems to prevent a more severe crisis. The compensation to patients, the preventive character, cost, and administrative conditions should be analysed [51].
However, despite “safe harbour” legislation (liability protection to physicians following guidelines in Oregon) to reform the malpractice system and improve patient safety, it is reported that such legislation would have changed the liability outcome in favour of the physician by only 1 percent of 266 claims (2002–2009) [52].
Significant differences exist in litigation rates and indemnity payments even in similar litigation systems in different counties (Spain and Massachusetts) [53].
Despite a no-fault system in Finland, claimants’ excess costs have not reduced adverse events. As a consequence, it has been demanded that claims analyses should not be restricted only to compensated claims [54].

9. Informed Consent

Online resources are crucial for providing health information to patients, but the quality of information about inguinal hernia surgery online is insufficient. There is a lack of detailed information about potential complications, making it challenging for patients to make informed decisions. Developing high-quality online resources is of utmost importance [55].
Informed consent for hernia surgery carries risks such as infection and bleeding. Surgeons must also address severe complications, including chronic pain, testicular issues, and visceral injury. Good informed consent practices are advantageous for both the patient and the surgeon [56].
Patients’ decision-making regarding elective surgical procedures depends on who informs them when they are informed about the procedure and whether patients have access to informative resources beforehand [57].
Cultural and religious differences should be taken into account when advising patients about inguinal herniotomy with mesh [58].
In men undergoing evaluation for inguinal hernia repair, providing a comprehensive overview of potential risks does not significantly heighten patient anxiety. Instead, it aids patients in making well-informed decisions before consenting to surgery, reducing the likelihood of future legal action [59].
Inguinal hernia repair may lead to complications like chronic pain and testicular issues. Failing to address these during informed consent could result in legal claims. Enhancing the consent process can improve patient satisfaction after inguinal hernia repair. Patients may not recall all the details, so repeating the necessary information and providing additional resources to reinforce the consent process is essential [60].
Consent practice in hernia surgery needs a standardised consent form and procedure [61].
Using pre-printed templates for consent forms and discharge summaries can improve the consent procedure. Some patients may prefer to give consent for an outpatient herniotomy. Patients may react more positively to the informed consent procedures when receiving information in hospitals or ambulatory centres. However, it is important to note that not all studies confirm this [62,63].
The quality of online patient information regarding complications of inguinal hernia repair is insufficient. Patient education should be improved on social media and official channels.

10. Recent Procedures at German Higher District Courts

The patient should be informed about alternative methods of inguinal hernia surgery and potential nerve and vas deferens injuries. Postoperative care should be error-free to prevent bleeding, infection, or circulatory problems. The informed consent procedure must occur well before the procedure to allow the patient to make an informed decision (File Number of the Court Decision and Comment) [64,65,66,67].

11. Mesh Court Procedures

Successful medico-legal claims can include cases such as intestinal perforation, delays in diagnosing small intestine adhesion obstruction, infertility due to adhesions, and pain. Adhesions associated with mesh may occur following laparoscopic inguinal hernia repairs [68].
In 2013, Josef E. Fischer proposed that mesh implantation could reduce the 4–6% recurrence rate but might lead to increased inguinodynia. Removing the mesh and affected nerves could alleviate severe pain, but triple neurectomy was only successful in 80% of patients. After mesh-based inguinal herniotomy, inguinodynia could affect up to 21% of patients. The author recommended suture repair, like Shouldice repair, over mesh repairs [69].
Laparoscopic mesh removal may be beneficial in selected patients with chronic groin pain following endoscopic and open inguinal hernia repair [70,71].
Inguinal hernia mesh repair studies have shown that the mesh or fixation method used does not significantly impact the outcome, pain levels, or hernia recurrence. Pain was reported in 7–8% of patients, with hernia recurrences occurring in 2–4% of cases. Less invasive fixation methods, such as adhesive or self-adhesive mesh, could be considered in Lichtenstein hernia repair [72].
Inguinal hernia repair with mesh has low complication rates and does not usually result in significant chronic pain. However, some patients, especially those who have researched mesh or had hernia recurrences, may anticipate issues with mesh usage and potential complications and expect recurrence and recovery challenges [73].
Lawsuits related to hernia mesh are widespread on social media in the USA but not well-known in Europe. The defendants in these cases are the manufacturers of the mesh. Claims for damages include death, infection, organ damage, autoimmune diseases, adhesions, and intestinal obstruction. As of April 2024, there are 25,389 pending cases, with $184 million set aside for settlements and $4.8 million for convictions [74].
Liability may arise if doctors use a mesh without adequate testing [75].

12. Conclusions

Chronic postoperative pain after inguinal hernia repair can lead to malpractice claims. Ultrasound examination is valuable in diagnosing chronic pain. Urological injuries may account for one-fifth of complications, while mesh infection can lead to hospital readmission, increased healthcare costs, and lawsuits. Proper informed consent is crucial; patients should be informed about alternative methods and potential complications.

Author Contributions

Both authors have equally contributed to the paper (conceptualization, methodology, investigation, draft preparation, writing review and editing, have read and agreed to the publication). All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Conflicts of Interest

There are no conflicts of interest.

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Holzheimer, R.G.; Hakim, N. The Impact of Social Media on Public Perception and Litigation in Hernia Surgery Complications: A Narrative Review. Complications 2024, 1, 51-60. https://doi.org/10.3390/complications1030009

AMA Style

Holzheimer RG, Hakim N. The Impact of Social Media on Public Perception and Litigation in Hernia Surgery Complications: A Narrative Review. Complications. 2024; 1(3):51-60. https://doi.org/10.3390/complications1030009

Chicago/Turabian Style

Holzheimer, René Gordon, and Nadey Hakim. 2024. "The Impact of Social Media on Public Perception and Litigation in Hernia Surgery Complications: A Narrative Review" Complications 1, no. 3: 51-60. https://doi.org/10.3390/complications1030009

APA Style

Holzheimer, R. G., & Hakim, N. (2024). The Impact of Social Media on Public Perception and Litigation in Hernia Surgery Complications: A Narrative Review. Complications, 1(3), 51-60. https://doi.org/10.3390/complications1030009

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