Rare late mesh complications following inguinal prolene hernia system hernioplasty: report of three cases

Inguinal Squamous Cell Carcinoma Presenting as a Marjolin Ulcer in the Absence of Mesh Infection: A Case Report

Inguinal hernias are the most common type of hernias, and most are repaired surgically with mesh placement to prevent future reoccurrence. Mesh infection and hernia recurrence are some of the rare complications of mesh placement, and chronic mesh infections increase the risk of squamous cell carcinoma at the site. Squamous cell carcinoma (SCC) in the setting of a mesh infection presents in a similar manner to a Marjolin ulcer and is treated with the removal of the tumor and degraded infected mesh. However, in this case, the patient presented atypically with an absence of mesh involvement. This report aims to explore the etiology of SCC due to mesh infections as well as describe the perplexing case of inguinal SCC in the absence of mesh involvement.

OUP accepted manuscript

Colocutaneous fistula associated with Crohn’s disease after mesh repair for inguinal hernia has not been previously reported in the literature. We report such case in an 83-year-old man following a preperitoneal repair of a left-sided inguinal hernia using Kugel patch. The patient has Crohn’s disease in remission status for 4 years. One month after inguinal hernia repair, he presented with fever and left-sided inguinal pain and swelling. Computed tomography revealed abscess formation in the preperitoneal and subcutaneous space of the left-sided inguinal region. Colonoscopy showed local exacerbation of Crohn’s disease in the sigmoid colon, and formation of fistula between the sigmoid colon and abdominal wall of the left-sided inguinal region. We performed mesh removal with Hartmann resection following percutaneous abscess drainage. The post-operative course was uneventful, and no sign of recurrence of the hernia was found for 3 years post-operatively.

Different etiopathogeneses in early-onset and late-onset inguinal hernia mesh infections in a prospectively evaluated cohort

INTRODUCTION

Inguinal hernia mesh infection (IHMI) is a rare but a significant problem. The aim of this study was to determine whether etiopathogeneses of early-onset and late-onset IHMIs differ in terms of the origin of infectious agents, and route of dissemination.

PATIENTS AND METHODS

This was a retrospective cohort study with prospective data collection of patients operated on from 2013 to 2015. Early-onset IHMI was defined as symptoms developed within one year after the index surgery, whereas late-onset IHMI was defined as infection developed later than a year after the index surgery. Age, gender, ASA score, BMI, time from index surgery, isolated infectious agents and possible pathogeneses were analyzed.

RESULTS

During the study period, 1438 patients underwent inguinal hernia repair. Sixteen patients (1.1%) had IHMI, of whom nine were early-onset and seven late-onset. The groups were comparable for age (p = .54), gender (p = 1.0), BMI (p = .79), and ASA score (p = 1.0). The most common infectious agent in early-onset IHMI was St. aureus, whereas Enterococci and Enterobacter prevailed in late-onset IHMI. The possible pathogenesis of IHMI in seven patients with early-onset IHMI was primary exogenous infection, whereas in patients with late-onset IHMI the pathogenesis might be hematogenous or contact spread. All patients with IHMI underwent mesh removal. In two patients (one from each group), partial mesh removal was performed previously and IHMI recurred.

CONCLUSIONS

Early-onset hernia mesh infection is mostly caused by St. aureus through exogenous contamination, whereas its late-onset counterpart might be a result of hematogenous or contact spread of intestinal flora.

Delayed enterocutaneous fistula formation secondary to an inverted non-absorbable suture post midline laparotomy closure

•

Such a delayed manifestation of enterocutaneous fistula secondary to a midline closure suture has not been previously described.

•

We recommend to investigate such patients with a contrast CT scan to visualise the anatomy and an MRI scan to exclude Crohn's disease.

•

The learning point is that inversion of the suture intra-peritoneally post midline laparotomy closure should be avoided.

Introduction

Enterocutaneous fistula is a well recognised complication of intra-abdominal surgery. Postoperatively, it may occur due to a small bowel injury or an anastomotic leak and usually presents within days or weeks after surgery.

Methods

We present a case report. Information was obtained through a retrospective review of the notes, clinic letters, images and the histology report.

Results

We present a case of a patient who developed an enterocutaneous fistula 34 years after panproctocolectomy for ulcerative colitis. Imaging was consistent with an enterocutaneous fistula arising from mid-small bowel. A laparotomy and small bowel resection was performed. The enterocutaneous fistula occurred due to an inverted non-absorbable suture post midline laparotomy closure.

Conclusion

Suture-related enterocutaneous fistula can be a rare delayed complication of a midline laparotomy closure when a knot is inverted intra-peritoneally. Consideration should be given to either leaving a knot in the subcutaneous fat tissue or feeding it between the rectus sheath and the suture bites.

Delayed abdominal wall abscess after abdomino-perineal resection simulating local recurrence of rectal cancer

Introduction

We report a rare case of delayed abdominal wall abscess after abdominoperineal resection (APR) for rectal cancer.

Case description

A 63-year-old woman was diagnosed with rectal cancer and received chemo-radiotherapy, followed by APR. One year after surgery, the patient complained of pain and skin redness in the lower abdomen. A low-density mass lesion with 5.9-cm diameter was found in the lower abdominal wall by computed tomography, which showed high uptake on positron-emission tomography. These findings suggested the possibilities of either delayed abscess formation or abdominal wall recurrence of rectal cancer with central necrosis. Percutaneous drainage was performed. The content was a purulent exudate, without neoplastic cells in the cytology. The lesion quickly disappeared after the drainage, and no recurrence of the tumor was observed for more than 2 years.

Discussion and evaluation

In this case, the un-absorbable yarn, such as silk, has not been used during the operation, no foreign body was retained in the abdominal wall, and there was no associated inflammatory bowel disease. Use of neoadjuvant chemoradiotherapy was the only possible cause of delayed abscess formation in this case.

Conclusion

In case local recurrence is suspected by imaging modalities in the postoperative of colorectal cancer, especially those with precedent chemoradiotherapy or radiotherapy, although rare, the possibility of a delayed abscess formation should also be considered.