Erosion of small intestine with necrotising fasciitis of over lying abdominal wall after expanded poly-tetrafluoroethylene mesh implantation: A rare complication after laparoscopic incisional hernia repair.

Complications such as bowel erosions, enterocutaneous fistulae are rare with the use of expandedpoly-tetrafluoroethylene (ePTFE) mesh in laparoscopic incisional hernia repair (LIHR). This unusual case patient presented to us with necrotising fasciitis of overlying anterior abdominal wall with peritonitis withsepticaemia and underwent aLIHR6 weeks before, which has not been reported till yet. We report a case of LIHR, presented to us with necrotising fasciitis of overlying anterior abdominal wall, peritonitis and septicaemia which was managed by small bowel segmental resection and exteriorisation of the ends, debridement of overlying anterior abdominal wall and maximum resection of implanted mesh. This case is unusual secondary to long experience with ePTFE mesh and the lack of published cases similar to this one. A brief review of relevant literature has been included in the article. We recommend pre-peritoneal placement of dual mesh fixed preferably by trans-abdominal polypropylene suture in LIHR.

INTRODUCTION

Prosthetic material used in laparoscopic incisional hernia repair (LIHR) carries a potential to induce severe complications when placed in the abdominal cavity. Complications such as the development of dense adhesions, bowel erosions and enterocutaneous fistulae have been reported.[1] We report a case of LIHR presented to us with peritonitis, necrotising fasciitis of overlying abdominal wall and septicaemia. Since this type of complication has not been frequently reported and since the mechanism of erosion in this particular patient appeared to be unusual, we decided to report this case in a patient with a remote expandedpoly-tetrafluoroethylene (ePTFE) incisional herniorrhaphy.

CASE REPORT

A 45-year-old lady was admitted to the hospital with 2-day history of pain in abdomen and vomiting. Six years prior to admission, the patient had a caesarean section delivery. She subsequently developed an incisional hernia and underwent a LIHR by an experienced laparoscopic surgeon 6 weeks before. An ePTFE mesh was placed intraperitoneally and fixed with tackers and trans-abdominal polypropylene sutures. Patient was alright for up to 1 month till she started developing vomiting on and off. She was conscious, oriented. Pulse rate was 120/min and blood pressure was 50mm Hg (systolic). There were added sounds on chest auscultation and on abdominal examination, there was mild distension, tenderness, rigidity, guarding and a 7cm fluctuant swelling in right lumbar quadrant with blackish discoloration of overlying skin (the hernia site). Haematological values were Hb, 7.5 g/dl; Total Leucocyte Count, 5,840 cells/cmm; serum biochemical values showed as blood glucose (R), 66 mg/dl;serum creatinine, 1.4 mg/dl; serum albumin, 1.3 g/dl; serum sodium, 142.6 meq/l; and serum potassium, 3.1 meq/l. Ultrasonography abdomen showed: loculated collection in pelvis (~60cc), parietal wall collection (~100cc) in right lower abdomen at the site of previous surgical site communicating with peritoneal cavity and associated scar dehiscence; X-ray chest poster o anterior view showed: patchy-confluent consolidation in bilateral lung fields.

Patient was admitted in intensive care unit (ICU). Intravenous fluids and inotropic drugs were given and eventually ventilatory support was given for difficulty in respiration and falling arterial oxygen saturation. On all life supports, patient was operated. Intraoperative findings were: necrotising fasciitis of overlying abdominal wall, infected mesh densely adhered to gut, feculent fluid, dense cohesive adhesions and two nearby small bowel perforations [Figures 1 and 2]. Liberal debridement of overlying anterior abdominal wall, maximum resection of implanted mesh, small bowel segmental resection and exteriorisation of bowel ends were done. Unfortunately, patient went into multiorgan dysfunction syndrome and expired on post-operative day 3.

Figure 1

Showing infected implanted expanded poly-tetrafluoroethylene mesh, dense adhesions and a spiral tack

Figure 2

Showing pieces of polypropylene component of the dual mesh adhered to the underlying tissues, necrotising fasciitis of overlying abdominal wall, pus flakes and feculent fluid

DISCUSSION

New prosthetic materials that present higher biocompatibility trigger less foreign body reaction and are more suitable for placement within the peritoneal cavity, provided the base for development of LIHR and triggered the expansion and popularity of this new technique. Despite the increasingly popularity of LIHR, long-term consequences of intraperitoneal implantation of synthetic mesh remain a concern.

In a large series of re-operations after LIHR, no or minimal adhesions to implanted ePTFE mesh was observed in 91% of cases and no severe cohesive adhesions were found.[2] In this series, in all cases mesh placement was done pre-peritoneally.

There are well-known complications of mesh hernia repair, however, including infection, seroma, adhesion formation, bowel obstruction and erosion into the hollow viscera.[34]

A case of enterocutaneous fistula secondary to the erosion of an ePTFE prosthesis into the jejunum is described.[4] In fact, the author's search of the literature revealed little documentation of any erosive complication associated with an ePTFE herniorrhaphy.

The mesh fixed to the abdominal wall with spiral tacks tended to increase the extent,type and tenacity of adhesions more than the mesh fixed with polypropylene suture (P<0.05).[5]

ePTFE mesh performs well and promotes few adhesions, but to minimize potentially serious complications, its edges must be secured around its entire circumference.

Recently, the authors were referred a patient who had developed necrotising fasciitis with peritonitis with septicaemia associated with ePTFE mesh herniorrhaphy. In this case, an ePTFE mesh overlapping the hernia defect margins by more than 5 cm was fixed intraperitoneally with double ring of tacks and trans-abdominal sutures. She presented to us 6 weeks later with necrotising fasciitis of overlying abdominal wall with peritonitis with septicaemia. Subsequently, on operation, it was found that this complication might have been developed because of bowel erosion due to mesh.

To conclude, the pre-peritoneal placement of dual mesh, fixed by trans-abdominal polypropylene suture in LIHR can prevent such complications.