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Jallali M, Chaouch MA, Zenati H, Hassine HB, Gafsi B, Noomen F. Complications unveiled: A detailed case report on mesh migration post-incisional hernia repair. Int J Surg Case Rep 2024; 121:109976. [PMID: 38954968 PMCID: PMC11263626 DOI: 10.1016/j.ijscr.2024.109976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Repairing incisional abdominal wall hernia with nonabsorbable meshes is one of the most common procedures in general surgery. Mesh migration into the intestine is rare but a serious complication. It can occur months or even years after surgery and often presents with vague abdominal pain, making diagnosis tricky. CASE PRESENTATION We report a rare case of a 52-year-old female presenting a small bowel obstruction secondary to mesh migration from the abdominal wall into the intestine, 10 years after repeated surgical repair of a ventral incisional hernia. At surgery, a mesh was migrated into a small bowl. The patient had a small bowel resection. The postoperative course was simple and the patient was discharged after 5 days. CASE DISCUSSION Incisional hernia repair with mesh is one of the most commonly performed surgical procedures worldwide. Many complications have been linked to the use of mesh; among the most frequently reported are seromas, hematomas, and infections. Mesh migration remains an uncommon event after incisional hernia repair, and even rarer when considering complete migration within the intestinal lumen. The exact cause of this complication remains unknown. Multiple hypotheses have been proposed for mesh migration. Abdominal pain, intermittent or persistent intestinal obstruction, mass formation, and viscus perforation represent the most common clinical manifestation. Total removal of the mesh via laparoscopy or laparotomy is recommended, along with either partial or entire resection of the organ. CONCLUSION Mesh migration is a an uncommon possible complication in case of incisional hernia mesh repair and it requires often surgical intervention.
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Affiliation(s)
- Maissa Jallali
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Mohamed Ali Chaouch
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia.
| | - Hanen Zenati
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Hiba Ben Hassine
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Besma Gafsi
- Department of Anesthesia, Monastir University Hospital, Monastir, Tunisia
| | - Faouzi Noomen
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
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Mourelatou R, Liatsos C, Bistaraki A, Nikou E. Intraluminal Migration of a Penrose Drain Presented with Hematochezia, after Lower Gastrointestinal Surgery. Surg J (N Y) 2022; 8:e279-e282. [PMID: 36225885 PMCID: PMC9550314 DOI: 10.1055/s-0042-1757603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/20/2022] [Indexed: 12/03/2022] Open
Abstract
Background Although surgical drains are widely used after lower gastrointestinal (GI) procedures, complications may occur. Specifically, sporadic cases of drain migration into a hollow viscus, most commonly regarding active drains and treated with surgical removal, have been reported. Herein, we present a case of a passive drain (penrose) migration into the colon, after segmental sigmoidectomy with primary anastomosis, presented with hematochezia. Methods A 37-year-old male patient suffering from colovesical fistula, due to sigmoid diverticulitis, underwent resection of the fistula, the involved sigmoid segment and the bladder opening, followed by primary anastomosis of the colon and primary closure of the bladder. A penrose catheter was positioned near the anastomosis. Results On 8th postoperative day (POD) the patient had three episodes of hematochezia and blood in the drain collection bag, followed by relative improvement. On 15th POD gas was observed on the drain's collection bag and a new episode of hematochezia led him to sigmoidoscopy. The endoscopy revealed the presence of the penrose drain intraluminally, protruding via an ulcer at the level of the anastomosis. The penrose repositioned outside the lumen and metallic clips were used to approximate the defect. The patient was then fully recovered, discharged, and the drain removed on follow-up. Conclusion To our knowledge this is the first report of drain migration presented with hematochezia, after lower GI surgery, avoided reoperation, and resolved with removal of the drain under direct endoscopic vision.
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Affiliation(s)
- Roza Mourelatou
- 2nd Department of General Surgery, 417 Army Share Fund Hospital, Athens, Greece,Address for correspondence Roza Mourelatou, PhD 2nd Surgical Unit, 417 Army Share Fund HospitalMonis Petraki 10-12, 11521, AthensGreece
| | - Christos Liatsos
- Department of Gastroenterology, 401 Army General Hospital, Athens, Greece
| | - Angeliki Bistaraki
- Department of Nursing, School of Health Sciences, Hellenic Mediterranean University, Athens, Greece
| | - Efstathios Nikou
- 2nd Department of General Surgery, 401 Army General Hospital, Athens, Greece
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Sahebally SM, Lim TZ, Azmir AA, Lu CT, Doudle M, Naik A, Nolan G, Papen MV. Prophylactic mesh placement at index permanent end colostomy creation to prevent parastomal hernia-an updated meta-analysis. Int J Colorectal Dis 2021; 36:2007-2016. [PMID: 33877438 DOI: 10.1007/s00384-021-03924-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Debate persists regarding the efficacy of prophylactic mesh insertion (PMI) at index permanent stoma creation to reduce the rate of parastomal hernia (PSH). This meta-analysis aimed to appraise all the latest evidence from newly published randomized controlled trials (RCTs) on PMI for PSH prevention. METHODS PubMed, EMBASE, and Cochrane databases were searched for relevant articles from inception until November 2020. All RCTs that reported on PMI at end colostomy creation with ≥ 12 months follow-up were included. The primary objective was the rate of clinical and radiological PSH while secondary objectives included number of PSH requiring repair and stoma (or mesh)-related complications. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. RESULTS Eleven RCTs were included capturing 1097 patients. The mean (SD) age was 67.9 (±9.4) years. On random effects analysis, prophylactic mesh appeared to reduce the rate of both clinical (OR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and radiological (OR = 0.39, 95% CI = 0.24 to 0.65, p = 0.0002) PSH. However, there was no difference in number of PSH requiring repair or stoma-related complications. On sensitivity analysis, when focusing on low-risk of bias studies, the benefit of prophylactic mesh in the retrorectus space was lost for both clinical (OR = 0.97, 95% CI = 0.62 to 1.51, p = 0.89) and radiological PSH (OR = 0.74, 95% CI = 0.46 to 1.18, p = 0.20). CONCLUSION PMI may reduce the rate of subsequent PSH. However, further studies are required to confirm these findings and to establish the optimal mesh position and shape before definite recommendations can be made.
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Affiliation(s)
- Shaheel M Sahebally
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia. .,Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Titus Z Lim
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Alisha A Azmir
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Cu Tai Lu
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Mark Doudle
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Arun Naik
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Gregory Nolan
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
| | - Michael Von Papen
- Department of Colorectal Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast, Queensland, 4215, Australia
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Yamada M, Miyasaka Y, Kanai T, Souda H, Uematsu K, Matsueda R, Yano N, Kawashiro S, Akamatsu H, Harada M, Hagiwara Y, Ichikawa M, Sato H, Nemoto K. Prediction of the minimum spacer thickness required for definitive radiotherapy with carbon ions and photons for pelvic tumors: an in silico planning study using virtual spacers. JOURNAL OF RADIATION RESEARCH 2021; 62:699-706. [PMID: 34059894 PMCID: PMC8273800 DOI: 10.1093/jrr/rrab047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/25/2021] [Indexed: 06/12/2023]
Abstract
We aimed to predict the minimum distance between a tumor and the gastrointestinal (GI) tract that can satisfy the dose constraint by creating simulation plans with carbon-ion (C-ion) radiotherapy (RT) and photon RT for each case assuming insertion of virtual spacers of various thicknesses. We enrolled 55 patients with a pelvic tumor adjacent to the GI tract. Virtual spacers were defined as the overlap volume between the GI tract and the volume expanded 7-17 mm from the gross tumor volume (GTV). Simulation plans (70 Gy in 35 fractions for at least 95% of the planning target volume [PTV]) were created with the lowest possible dose to the GI tract under conditions that meet the dose constraints of the PTV. We defined the minimum thickness of virtual spacers meeting D2 cc of the GI tract <50 Gy as 'MTS'. Multiple regression was used with explanatory variables to develop a model to predict MTS. We discovered that MTSs were at most 9 mm and 13 mm for C-ion RT and photon RT plans, respectively. The volume of overlap between the GI tract and a virtual spacer of 14 mm in thickness (OV14)-PTV was found to be the most important explanatory variable in the MTS prediction equation for both C-ion and photon RT plans. Multiple R2 values for the regression model were 0.571 and 0.347 for C-ion RT and photon RT plans, respectively. In conclusion, regression equations were developed to predict MTS in C-ion RT and photon RT.
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Affiliation(s)
- Masayoshi Yamada
- Corresponding author. Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan. ; Tel: +81-23-628-5386
| | - Yuya Miyasaka
- Department of Heavy Particle Medical Science, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Takayuki Kanai
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Hikaru Souda
- Department of Heavy Particle Medical Science, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Ken Uematsu
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Rei Matsueda
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Natsuko Yano
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Shohei Kawashiro
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Hiroko Akamatsu
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Mayumi Harada
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Yasuhito Hagiwara
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Mayumi Ichikawa
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Hiraku Sato
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
| | - Kenji Nemoto
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata 990-9585, Japan
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Leach JR, Manoukian B, Stewart L. Mesh on the move: a case report of total transmural surgical mesh migration causing bowel obstruction. Clin J Gastroenterol 2020; 14:136-140. [PMID: 33241525 DOI: 10.1007/s12328-020-01291-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/28/2020] [Indexed: 08/30/2023]
Abstract
We present the case of a 60-year-old man with a complex medical history, presenting to the hospital with generalized weakness and found to be markedly hyperglycemic. Early in the patient's hospital course, he developed abdominal pain and was found to have a small bowel obstruction secondary to intraluminal migrated surgical mesh entrapped in the terminal ileum. The bowel obstruction was relieved surgically with uncomplicated mesh removal and ileocecectomy. Surgical mesh migration is a relatively rare complication of hernia repair and abdominal wall reconstruction, and intraluminal mesh migration is an even more rare variant. Our case demonstrates key clinical and imaging features and serves as an important example of how such cases may present.
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Affiliation(s)
- Joseph Ryan Leach
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA. .,Department of Radiology, San Francisco Veterans Affairs Medical Center, 4150 Clement St, Building 200, Room 2D-008, San Francisco, CA, 94121, USA.
| | - Bryan Manoukian
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Lygia Stewart
- Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Lee Y, Bae BN. Transmural Mesh Migration From the Abdominal Wall to the Rectum After Hernia Repair Using a Prolene Mesh: A Case Report. Ann Coloproctol 2020; 37:S28-S33. [PMID: 32674553 PMCID: PMC8359694 DOI: 10.3393/ac.2020.04.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/19/2020] [Indexed: 12/29/2022] Open
Abstract
Mesh erosion or migration is a rare and late complication after hernia repair. Its incidence is increasing as the utilization of prosthetic mesh gains popularity for abdominal hernia repair. However, mesh migration is exceedingly rare and its clinical presentation is atypical and diverse. Therefore, the management of mesh migration should be individualized to each patient. This research reports the case of a 94-year-old man with transmural migration of Prolene mesh (Ethicon) from the abdominal wall to the rectum 14 years after incisional hernia repair. He presented with only chronic abdominal pain and constipation. Migration of the mesh and a fistula between the right abdominal wall and transverse colon was observed on computed tomography. The mesh was evacuated manually from the anus without any sequelae. These findings made this case atypical, since complete transluminal migration of mesh is exceedingly rare and mesh erosion or migration requires surgical treatment in many cases.
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Affiliation(s)
- Yujin Lee
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Byung-Noe Bae
- Department of General Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Yamada M, Sato H, Ieko Y, Miyasaka Y, Kanai T, Yano N, Ono T, Akamatsu H, Harada M, Ichikawa M, Teranishi Y, Kikuchi Y, Nemoto K. In silico comparison of the dosimetric impacts of a greater omentum spacer for abdominal and pelvic tumors in carbon-ion, proton and photon radiotherapy. Radiat Oncol 2019; 14:207. [PMID: 31752932 PMCID: PMC6868713 DOI: 10.1186/s13014-019-1411-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/30/2019] [Indexed: 02/06/2023] Open
Abstract
Purpose The purpose of this study was to compare carbon-ion (C-ion), proton and photon radiotherapy (RT) plans with regard to dose reduction of the gastrointestinal (GI) tract by using a greater omentum spacer (GO spacer). Methods We retrospectively retrieved data for ten patients who received the GO spacer as surgical spacer placement for abdominal and pelvic tumors. Simulation plans were created on pre-spacer Computed Tomography (CT) and post-spacer CT for C-ion RT, proton RT and photon RT to compare the dose of the GI tract. The plans were normalized so that at least 95% of the planning target volume (PTV) received 70 Gy (relative biological effectiveness equivalent) delivered in 35 fractions. All plans were created with the lowest possible dose to the GI tract under conditions that meet the dose constraints for the PTV and spinal cord (maximum dose < 45 Gy). The part of the GI tract to be evaluated was defined as that most adjacent to the PTV. C-ion RT plans and proton RT plans were calculated by a spot scanning technique, and photon RT plans were calculated employing by fixed-field intensity-modulated radiation therapy. Results D2 cc and V10–70 of the GI tract were significantly lower on post-spacer plans than on pre-spacer plans for all three RT modalities. Regarding post-spacer plans, D2 cc of the GI tract was significantly lower on C-ion RT plans and proton RT plans than on photon RT plans (C-ion vs photon p = 0.001, proton vs photon p = 0.002). However, there was no significant difference between C-ion RT plans and proton RT plans for D2 cc of the GI tract (C-ion vs proton p = 0.992). In the photon RT plan for one patient, D2 cc of the GI tract did not meet < 50 Gy. Conclusions The GO spacer shows a significant dose reduction effect on the GI tract.
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Affiliation(s)
- Masayoshi Yamada
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata, Japan.
| | - Hiraku Sato
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata, Japan
| | - Yoshiro Ieko
- Department of Heavy Particle Medical Science, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata, Japan
| | - Yuya Miyasaka
- Department of Heavy Particle Medical Science, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata, Japan
| | - Takayuki Kanai
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata, Japan
| | - Natsuko Yano
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata, Japan
| | - Takashi Ono
- Department of Radiation Oncology, Southern Tohoku Proton Therapy Center, 7-172, Yatsuyamada, Koriyama, Fukushima, Japan
| | - Hiroko Akamatsu
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata, Japan
| | - Mayumi Harada
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata, Japan
| | - Mayumi Ichikawa
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata, Japan
| | - Yasushi Teranishi
- Department of General Surgery, Southern Tohoku Proton Therapy Center, 7-172, Yatsuyamada, Koriyama, Fukushima, Japan
| | - Yasuhiro Kikuchi
- Department of Radiation Oncology, Southern Tohoku Proton Therapy Center, 7-172, Yatsuyamada, Koriyama, Fukushima, Japan
| | - Kenji Nemoto
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, 2-2-2, Iida-Nishi, Yamagata, Japan
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Isherwood J, Stephenson J, Rees Y, Bhardwaj N. Unusual case of post-operative small bowel obstruction. ANZ J Surg 2019; 90:389-391. [PMID: 31066185 DOI: 10.1111/ans.15170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/03/2019] [Indexed: 11/30/2022]
Affiliation(s)
- John Isherwood
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
| | - James Stephenson
- Department of Radiology, Leicester General Hospital, Leicester, UK
| | - Yvonne Rees
- Department of Radiology, Leicester General Hospital, Leicester, UK
| | - Neil Bhardwaj
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
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Chronic anemia due to transmural e-PTFE anti-adhesive barrier mesh migration in the small bowel after open incisional hernia repair: A case report. Int J Surg Case Rep 2018; 53:54-57. [PMID: 30384142 PMCID: PMC6214886 DOI: 10.1016/j.ijscr.2018.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/20/2018] [Accepted: 10/07/2018] [Indexed: 11/23/2022] Open
Abstract
Mesh related unusual complication. Intraluminal mesh migration. Mesh erosion.
Introduction Meshes are commonly employed in abdominal hernia repair to reduce recurrence rates. Prosthetic repair, however, increases the risk of mesh related complications, including migration into adjacent viscera and erosion which can occur as uncommon and can be difficult to be diagnose. Presentation of case This is a case of transmural migration of composite mesh into the bowel, presenting as chronic abdominal pain and anemia 14 years after incisional hernia repair. Discussion Mesh implantation in hernia repair has increased the incidence of complications, such as seroma, hematoma and infection. Migration into adjacent viscera and erosion may present as complications related to the use of meshes. Their precise frequency after abdominal wall hernia repair is not well known and their late occurrence can make the diagnosis difficult. Conclusion Transmural migration of composite mesh is an uncommon complication of incisional hernia repair. Its pathogenesis is still not completely clear but it has been reported many years after implant surgery. It should be considered in a typical presentation of patients with history of previous prosthetic ventral hernia repair.
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Abstract
INTRODUCTION Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. METHODS An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients. CONCLUSIONS The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.
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Tsapralis D, Vasiliades G, Zaxou Z, Delimpaltadaki M, Margetousakis TH, Papadakis H, Machairas A, Misiakos EP. Bowel obstruction secondary to migration of a Ventralex mesh: report of a rare complication. Hernia 2018; 22:711-714. [PMID: 29372340 DOI: 10.1007/s10029-017-1720-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 12/27/2017] [Indexed: 11/24/2022]
Affiliation(s)
- D Tsapralis
- Department of General Surgery, General Hospital/Health Center of Ierapetra, Ierapetra, Crete, Greece
| | - G Vasiliades
- Department of General Surgery, General Hospital/Health Center of Ierapetra, Ierapetra, Crete, Greece
| | - Z Zaxou
- Department of General Surgery, General Hospital/Health Center of Ierapetra, Ierapetra, Crete, Greece
| | - M Delimpaltadaki
- Department of General Surgery, General Hospital/Health Center of Ierapetra, Ierapetra, Crete, Greece
| | - T H Margetousakis
- Department of General Surgery, General Hospital/Health Center of Ierapetra, Ierapetra, Crete, Greece
| | - H Papadakis
- Department of General Surgery, General Hospital/Health Center of Ierapetra, Ierapetra, Crete, Greece
| | - A Machairas
- 3rd Department of General Surgery, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, Chaidari, Athens, Greece
| | - E P Misiakos
- 3rd Department of General Surgery, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, Chaidari, Athens, Greece.
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Soto Sánchez A, Sánchez González JM, Gambra Michel L. Bowel obstruction secondary to intraluminal migration of the abdominal wall mesh. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:670. [PMID: 28741363 DOI: 10.17235/reed.2017.4916/2017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Eventration is an important public health problem due to its high incidence of around 12-15% in all laparotomies performed. The repair of an eventration has a 5-15% risk of complications. In recent years, the repair with prosthetic material has resulted in additional complications.
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Affiliation(s)
- Ana Soto Sánchez
- Cirugía General, Hospital Universitario Nuestra Señora de Candelaria, España
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Yang GPC. From intraperitoneal onlay mesh repair to preperitoneal onlay mesh repair. Asian J Endosc Surg 2017; 10:119-127. [PMID: 28547932 DOI: 10.1111/ases.12388] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 04/12/2017] [Indexed: 11/30/2022]
Abstract
Laparoscopic repair for ventral and incisional hernias was first reported in the early 1990s. It uses intraperitoneal only mesh placement to achieve a tension-free repair of the hernia. However, in recent years, there has been greater concern about long-term complication involving intraperitoneal mesh placement. Many case reports and case series have found evidence of mesh adhesion, mesh fistulation, and mesh migration into hollow organs including the esophagus, small bowel, and large bowel, resulting in various major acute abdominal events. Subsequent management of these complications may require major surgery that is technically demanding and difficult; in such cases, laparotomy and bowel resection have often been performed. Because of these significant, but not common, adverse events, many surgeons favor open sublay repair for ventral and incisional hernias. Investigators are therefore searching for a laparoscopic approach for ventral and incisional hernias that might overcome the mesh-induced visceral complications seen after intraperitoneal only mesh placement repair. Laparoscopic preperitoneal onlay mesh is one such approach. This article will explore the fundamental of intraperitoneal only mesh placement and its problems, the currently available peritoneal visceral-compatible meshes, and upcoming developments in laparoscopic ventral and incisional hernia repair. The technical details of preperitoneal onlay mesh, as well as its potential advantages and disadvantages, will also be discussed.
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Picchio M, Muggianu A, Mancini F, Tintisona O, Spaziani E. Complete mesh migration into the small bowel after incisional hernia repair: a case report and literature review. Acta Chir Belg 2017; 117:118-121. [PMID: 27609029 DOI: 10.1080/00015458.2016.1229399] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Mesh migration into the intestine is very rare after incisional hernia repair. CASE REPORT We report the case of transmural mesh migration from the abdominal wall into the small bowel presenting as recurrent small bowel obstruction 18 years after repeated surgical repair of an incisional ventral hernia. At surgery, a mesh was found inside the resected ileal loop. DISCUSSION Mesh migration into the intestine is a possible, although very rare, complication after incisional hernia repair with nonabsorbable meshes. It tends to occur late with obstructive symptoms, especially if the small intestine is involved. Avoiding the direct contact between the mesh and the intestinal wall may help to reduce this complication.
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Affiliation(s)
- Marcello Picchio
- Department of Surgery (Chief Dr. Claudio Mascetti), “P. Colombo” Hospital, Velletri, Rome, Italy
| | - Andrea Muggianu
- Department of Surgery (Chief Dr. Claudio Mascetti), “P. Colombo” Hospital, Velletri, Rome, Italy
| | - Francesca Mancini
- Department of Anesthesiology and Intensive Care (Chief Dr. Maurizio Capogrossi), “P. Colombo” Hospital, Velletri, Rome, Italy
| | - Orlando Tintisona
- Department of Surgery (Chief Dr. Claudio Mascetti), “P. Colombo” Hospital, Velletri, Rome, Italy
| | - Erasmo Spaziani
- Department of Surgery, Sapienza University of Rome, Polo Pontino, Terracina, Latina, Italy
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Tung KLM, Cheung HYS, Tang CN. Non-healing enterocutaneous fistula caused by mesh migration. ANZ J Surg 2015; 88:E73-E74. [PMID: 26246228 DOI: 10.1111/ans.13253] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Karen Lok Man Tung
- Department of Surgery; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | | | - Chung Ngai Tang
- Department of Surgery; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
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Millas SG, Mesar T, Patel RJ. Chronic abdominal pain after ventral hernia due to mesh migration and erosion into the sigmoid colon from a distant site: a case report and review of literature. Hernia 2013; 19:849-52. [DOI: 10.1007/s10029-013-1182-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 10/31/2013] [Indexed: 11/30/2022]
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18
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Voisard G, Feldman LS. An unusual cause of chronic anemia and abdominal pain caused by transmural mesh migration in the small bowel after laparoscopic incisional hernia repair. Hernia 2013; 17:673-7. [DOI: 10.1007/s10029-013-1127-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 06/11/2013] [Indexed: 02/07/2023]
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Ogino T, Sekimoto M, Nishimura J, Takemasa I, Mizushima T, Ikeda M, Yamamoto H, Doki Y, Mori M. Intraluminal migration of a spacer with small bowel obstruction: a case report of rare complication. World J Surg Oncol 2012; 10:30. [PMID: 22309780 PMCID: PMC3293069 DOI: 10.1186/1477-7819-10-30] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 02/06/2012] [Indexed: 11/10/2022] Open
Abstract
The spacer placement is a prevalent procedure to separate the surrounding normal tissues from locally recurrent rectal tumor before the application of radiotherapy. However, complications could occur due to the foreign nature of the spacer. This report describes a case of 60-year-old man who had undergone radiotherapy two years earlier for a recurrent rectal tumor and presented with small bowel obstruction. A spacer was used before radiotherapy. Radiological assessment and laparotomy revealed the presence of the spacer inside the small bowel lumen. It is possible that the spacer established contact with the intestine, elicited local inflammatory reaction that facilitated the complete penetration of the intestinal wall without causing any clinical symptoms.
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Affiliation(s)
- Takayuki Ogino
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
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