A rare complication following laparoscopic TEP repair: case report and discussion of the literature

Delayed laparoscopic mesh infection presenting as an abdominal mass

A 56-year-old man presented with a delayed mesh infection 8 years following an elective laparoscopic totally extraperitoneal (TEP) bilateral hernia repair. Sterile pus was drained percutaneously as a temporising measure prior to removal of the right-hand mesh; the left-sided mesh was adherent to the femoral vessels and minimally contaminated. Delayed mesh infection is a rare occurrence. This case is the fourth example and the longest following initial operation. Removal of the infected mesh is advocated.

Late onset mesh infection following laparoscopic inguinal hernia repair

In our series of 710 consecutive laparoscopic total-extra-peritoneal hernia repairs over a period of 10 years (2001-2010), the authors report a rare case of delayed mesh infection developing 7 years postoperatively. A 56-year-old patient presented with diarrhoea and fullness in right iliac fossa region. Radiological imaging confirmed a floating mesh in a fluid-containing cavity. Subsequent exploration revealed a large preperitoneal cavity containing 550 ml of pus with a floating mesh in it. The mesh was removed and the patient was discharged after making a good recovery.

Leucocyte count and oral temperature are a useful guide to selecting women with right iliac fossa pain for diagnostic laparoscopy

INTRODUCTION

In women, negative appendicectomy rates can be as high as 34%. A 5-fold reduction is possible with diagnostic laparoscopy. A selective policy is favoured as indiscriminate use may increase postoperative morbidity. Scoring systems are helpful but not used widely due to their complexity. The value of leucocyte count and temperature in selecting women with right iliac fossa pain for diagnostic laparoscopy is investigated.

PATIENTS AND METHODS

Over a 12-month period, admission leucocyte count and temperature data were obtained from women undergoing appendicectomy. Cohorts were sub-categorised by age (< 20, 21-40 and > 40 years) and the proportion of negative (normal appendix) and positive (inflamed, gangrenous or perforated appendix) appendicectomies compared.

RESULTS

In 100 women, 11% had leucocyte counts and temperature > or = 11 x 10(9)/l and 38 degrees C, respectively; all had appendicitis. In 50%, leucocyte counts and temperature were > or = 11 x 10(9)/l and < 38 degrees C; negative appendicectomies occurred in 13.8% < 20 years, 10% > 40 years (P < 0.01) and 27.3% aged 21-40 years (P = 0.086). In 39%, the negative appendicectomy rate was > or = 36.8% when leucocyte count and temperature were < 11 x 10(9)/l and 38 degrees C (P = 0.1).

CONCLUSION

Diagnostic laparoscopy should be considered in all women when leucocyte counts and temperature are > or = 11 x 10(9)/l and 38 degrees C and for females aged 21-40 years when these values are > or = 11 x 10(9)/l and < 38 degrees C.

Sigmoid colon fistula following totally extraperitoneal hernioplasty: an improper treatment for mesh infection or iatrogenic injury?

BACKGROUND

There are only a few reports of severe mesh-related complications, and major bowel complications after totally extraperitoneal (TEP) hernioplasty are also rare.

CASE REPORT

A 75-year-old male patient, who had undergone TEP hernioplasty for a left inguinal hernia 2 months previously, presented with a left inguinal swelling that was found to be due to sigmoid colon-related mesh complications following TEP hernioplasty.

CONCLUSIONS

Infection is an accepted complication of hernia operation; however, it may be more serious following laparoscopic techniques. Successful TEP hernioplasty requires adequate dissection and complete exposure and coverage of all potential sites that cause inguinal hernia. If infection and suppuration are resistant to conservative methods or occur in the early postoperative period, aggressive imaging study and treatment provides definitive treatment and reduces the burden of complications.

Serious life-threatening complication 5 years after laparoscopic totally extraperitoneal hernia repair: case report and discussion of the literature

PURPOSE

The purpose of this paper is to report the case of a serious life-threatening infection of the mesh occurring 5 years after totally extraperitoneal (TEP) hernia repair and to highlight the persistent risk of infection that may exist even after a long period following the primary repair. We also aim to raise the awareness of surgeons to the subtle presentation.

METHODS

We have reviewed the clinical presentation, past medical history and relevant pre-operative and post-operative investigations in a case of mesh infection 5 years after primary surgery. We have also reviewed the literature regarding long-term complications that may occur after TEP repair.

RESULTS

A 62-year-old man presented with severe mesh infection 5 years and 4 months after primary bilateral TEP hernia repair. He rapidly progressed into septic shock and had to be managed in the intensive care unit. He is a current smoker of 30 pack years. Post-operative contrast computed tomography (CT) revealed previously undiagnosed diverticuli scattered throughout the colon with points of minor narrowing at the sigmoid and transverse colons.

CONCLUSION

Although the risk of mesh infection following TEP hernia repair is small, it persists for more than 5 years and probably as long as the mesh remains in the body. Our report also raises the question as to whether there is a specific long-term risk of mesh infection following TEP hernia repair in patients with underlying inflammatory bowel disease and/or chronic heavy smoking. This needs to be studied prospectively.

NOTES new frontier: Natural orifice approach to retroperitoneal disease

AIM: To develop a pure transvaginal access to the retroperitoneum, that is simple, reproducible and uses endoscopic material available on the market.

METHODS: From February 2008 to April 2009, 31 pigs were operated on, with 17 as an acute experiment and 14 with a survival protocol. The animals were placed in a supine position and a 12-mm double-channel endoscope (Karl Storz™, Tuttlingen) was used for vision and dissection. During the same time period, the access experiment was reproduced on 3 human cadavers using material similar to that used in the animal model.

RESULTS: In the animal model, 37 interventions were done on the kidney, adrenal gland and pancreas. The mean time to fashion the access was 10 min (range 5 to 20 min). No intraoperative death was observed. Two major (5%) intraoperative complications occurred: one hemorrhage on the aorta and one tearing of the right renal vein. Peritoneal laceration was encountered in 5 cases without impairing the planned task. In the survival group, good clinical outcome was observed at a mean follow-up of 3 wk (range 2 to 6 wk). In the 3 cadavers, access was performed correctly. The mean time to fashion the access was 52 min (range 40 to 60 min). All the anatomical landmarks described in the pig model were clearly identified in the same sequence.

CONCLUSION: A retroperitoneal natural orifice translumenal surgical transvaginal approach is feasible in both animal and human models and allows performance of a large panel of interventions.