Polypropelene mesh eroding transverse colon following laparoscopic ventral hernia repair.

Polypropylene mesh when used in laparoscopic ventral hernia repair can produce the worst complication such as enterocutaneous fistula. We report an interesting case of incisional hernia operated with laparoscopic polypropylene mesh hernioplasty who subsequently developed an enterocutaneous fistula 1 month after surgery. A fistulogram showed dye entering into the transverse colon. On exploration, the culprit polypropylene mesh was found to have eroded into the mid-transverse colon causing the fistula. Resection and end-to-end anastomosis of the colon were done with the removal of the mesh. On literature review, polypropylene mesh erosion in to transverse colon is rare.

INTRODUCTION

Of all hernias encountered, incisional (ventral) hernia can be the most frustrating and difficult to treat. They usually occur as the result of a failure of fascial tissues to heal and close following laparotomy. The use of polypropylene mesh was initially reported by Usher as a means of repairing incisional hernias. Meanwhile, about 1 million meshes are implanted worldwide per year. The most common complication associated with polypropylene mesh is wound infection, and this is often managed conservatively with antibiotic therapy. Fistula formation from a polypropylene mesh has been reported to occur particularly if the prosthetic mesh is placed adjacent to the stomach or in contact with the small or large intestine.[1]

CASE REPORT

A 60-year-old man presented to us with a chronic foul smelling discharge with a typical history of passage of gas from a subumbilical discharging sinus for 6 months, with a history of repair of an incisional hernia following an open truncal vagotomy and gastro-jejunostomy. The incisional hernia was repaired with laparoscopic polypropylene mesh hernioplasty and 1 month after the surgery, he had developed the chronic discharging sinus. He was treated conservatively for more than 6 months without any result before presenting to our hospital. On fistulogram the dye entered the transverse colon. Therefore, he was planned for an exploratory laparotomy [Figures 1 and 2].

Figure 1

Fistulogram showing dye entering to colon

Figure 2

Polypropylene mesh eroding colon

Operative procedure

The abdomen was opened through a mid-line incision following a no. 10 infant feeding tube placed in the fistula tract. As expected, a part of the culprit polypropylene mesh was found to have eroded the mid-transverse colon, causing fistula.

Primary resection and end-to-end anastomosis of the transverse colon were done along with the removal of the polypropylene mesh and the fistulous tract. Abdomen was closed with non-absorbable sutures.

Post-operative period

Post-operative recovery was uneventful, and the patient was discharged on the eighth post-operative day, with follow-up at regular intervals.

DISCUSSION

The laparoscopic approach is widely accepted worldwide for management of ventral hernias. It also helps to identify additional hernial defects (Swiss cheese) in the anterior abdominal wall during repair. The goal of dissection is to provide a minimum of 5 cm overlap of the mesh beyond the edges of the hernia defect. In the present era, ventral hernias are repaired by the laparoscopic intraperitoneal onlay mesh (IPOM) technique using tissue separating/dual meshes to reduce adhesive complications;[2] few surgeons are trying to use the laparoscopic IPOM technique with polypropylene mesh by raising a flap such as Tandem PH domain containing protein (TAPP), even though the cost factor is taken care of but the long-term results of this technique is not evaluated till date.

“Protein absorption theory” is the most acceptable theory regarding the incorporation of mesh into surrounding tissues (by inducing foreign body reaction).

Intraperitoneal placement of a polypropylene mesh has a high propensity for complications such as seroma, wound infection, adhesions, recurrence, enterocutaneous fistula, etc., and that is the reason why people are switching over to tissue separating meshes.[34] Tissue separating prosthetic meshes are partially bioabsorbable meshes.

Partially bioabsorbable mesh – sepramesh (Genzyme Corp. General Division's Nasdaq: GENZ) and proceed (Cincinnati, USA) – a thin coating of bioabsorbable material layer on polypropylene mesh, gore-tex, physio etc are now the prosthesis of choice in laparoscopic ventral hernia repair by IPOM technique.[5] The prosthesis is fixed in place with either transfascial sutures or tacks (Pro tack/Secure strap) placed circumferentially in a double crown fashion.[2]

Mesh erosion into caecum, ascending colon, rectum (following mesh rectopexy), stomach, small intestines, and bladder is available in the literature, but erosion into transverse colon is rare.

CONCLUSION

Hence we conclude in the present era in a laparoscopic ventral/incisional hernia repair only tissue separating/dual meshes should be used, so that the inadvertent complications like the one described in this case can be minimised. Some surgeons even though are using polypropylene mesh in the IPOM technique to cut down on the cost of surgery, they should resist themselves from using polypropylene mesh in the IPOM technique, rather if a surgeon contemplates to use a polypropylene mesh in laparoscopic ventral hernia repair, then he should create a preperitoneal flap for placement of mesh, though it still carries a risk for adhesion.