Incisional hernia repair surgery is commonly performed by using a synthetic mesh; due to its low complication rate. This article describes the management of a patient with mesh erosion into the small bowel, a rare complication of mesh-based ventral hernia repair. Fatigue secondary to iron-deficiency anemia and disfigurement from his hernia were his only symptoms. The patient was conservatively managed for several years due to the risks associated with restorative surgery. Eventually, due to deterioration of his health as well as advances in the techniques of abdominal wall reconstruction, the patient underwent surgery. The patient made excellent recovery. The complications associated with the synthetic mesh are likely to be very underreported. This article discusses the factors leading to mesh erosion, including mesh type, fixation methods, mesh migration, and mesh position, and it emphasizes the importance of reporting and following up hernia patients to advance the science behind mesh technology and surgical techniques surrounding ventral hernia repair.
Keywords: General surgery, hernia, hernia repair, incisional hernia, mesh bezoar, mesh erosion
| Key Messages:|| |
Mesh erosion resulting in a mesh bezoar is a rare, underreported complication of mesh use for hernia repair
Factors leading to mesh erosion include mesh material, mesh positioning, and mesh fixation
Mesh removal is the only definitive treatment available
| Introduction|| |
In 2019, the Australian private sector saw 16,727 mesh-based incisional hernia surgeries performed due to their lower recurrence rate of 24% versus 43% for suture repair., However, major mesh-associated complications, including infection, mechanical failure, pain, foreign body reaction, and mesh erosion, are underreported. We report a rare case of meshoma erosion into the small bowel, presenting with iron-deficiency anemia.
| Case Report|| |
A 74-year-old man had an intraperitoneal synthetic mesh-based incisional hernia repair after a Hartmann’s procedure reversal for a perforated sigmoid diverticulum 10 years earlier. The hernia subsequently recurred with a significant loss of domain [Figure 1] and [Figure 2]. He experienced fatigue secondary to iron-deficiency anemia requiring regular iron infusions. His complex medical background included unprovoked deep vein thrombosis and pulmonary embolism managed with rivaroxaban, type two diabetes mellitus managed with oral hypoglycemic agents, and ischemic heart disease treated with coronary artery bypass and stenting.
Endoscopy and colonoscopy were normal. Magnetic resonance enteroclysis suggested small bowel ulceration. Computer tomography scan revealed mesh erosion in the small bowel [Figure 3]. Due to the patient’s perioperative risk, corrective surgery was deferred for eight years. Given ongoing symptoms and improved abdominal wall reconstruction techniques, the patient was finally referred to our unit for surgery.
The patient had Botulinum toxin injections to bilateral oblique and transversus muscles four weeks pre-op. Cefazolin and metronidazole were administered intraoperatively. After a midline incision and extensive adhesionolysis, the foul-smelling intraluminal meshoma that created a fistula involving two separate small bowel loops was isolated, resected and continuity was reestablished with two separate small bowel anastomoses [Figure 4]. Rives-Stoppa ventral hernia repair using bioabsorbable 20 cm × 30 cm GORE Bio-A mesh (poly (glycolide: trimethylene carbonate) copolymer (PGA:TMC)) was fixed in the retro-rectus plane to repair the hernia of the same size with 2-0 polydiozanone sutures (PDS). Bilateral external oblique release was required for the advancement of rectus muscles [Figure 1] and [Figure 2].
One-year post-op, this patient had no clinical or radiological signs of recurrent hernia. His iron deficiency anemia has resolved.
| Discussion|| |
Visceral organ erosion, a complication of mesh repair, can range from asymptomatic and/or incidental, to chronic pain, bowel obstruction, enterocutaneous fistula, or bleeding. Erosion incidence is likely underreported due to inconsistent definitions of complications after ventral hernia surgery and the lengthy timeframe until presentation.
Mesh erosion after ventral hernia repair is influenced by the mesh used, fixation methods, mesh migration, and mesh position.
Traditionally, the synthetic mesh has been reserved for clean wounds and the biologic mesh has been used for contaminated wounds due to better incorporability into host tissue., Biosynthetic mesh, such as the GORE BIO-A mesh used in this patient, has been developed as a cheaper alternative to the biologic mesh to allow slower degradation via hydrolysis (over seven months), enabling it to retain strength for a longer time in patients undergoing complex abdominal wall reconstruction. However, more recently, in line with growing clinical evidence, the largest study on mesh type in contaminated ventral hernia repair has shown a lower incidence of reoperation, surgical site infection, wound opening, as well as percutaneous drainage among patients utilizing synthetic mesh compared with biologic and biosynthetic mesh. Given the cost of biologic and biosynthetic mesh on the health-care economy, future guidelines comparing all three types of mesh should address the limitations of this study, including small sample sizes, short follow-up, and control for confounding medical comorbidities that can influence postoperative outcomes in order to make informed decisions about an ideal mesh for use in ventral hernia repair.
Mesh fixation also affects the strength and degree of mesh movement. Fixation is required to keep the mesh in place until tissue ingrowth is completed, which is usually two to three weeks post-op. Sutures are common in open repairs, and tacks are common in laparoscopic repairs. Risks of sutures include adhesions and inadvertent picking of the small bowel whereas tacks can cause nerve or visceral injury. Glues, however, are atraumatic, quicker in open hernia repairs, less painful, and comparable with sutures in terms of recurrence and wound infection rates but higher costs limit widespread adoption. Research into the optimal fixation method tailored to mesh type and the size and location of hernias is also required.
Mesh migration is another contributor. Primary mesh migration occurs early post-op due to inadequate fixation or external forces promoting movement. Secondary migration then occurs due to foreign body reactions and tissue erosion preventing normal scar healing, resulting in mechanical instability. The mesh then becomes encapsulated by omentum, creating a channel into the hollow organs propagated by inflammation and peristalsis. Concomitant superficial wound infections create a bacterial biofilm around the mesh, resulting in painless mesh migration through tissue. Eventually, the mesh successfully crosses the entire colonic wall lumen, leading to serious complications such as gastrointestinal perforation and abdominal sepsis.
Mesh position is another factor. Avoiding direct contact between the mesh and the bowel through intraperitoneal mesh placement is recommended, making the preperitoneal or retro-rectus mesh safer as the mesh is pushed against the abdominal wall by intraabdominal pressure, enabling rapid tissue integration without traumatic mesh fixation. Emerging techniques, including the enhanced-view totally extraperitoneal (eTEP) approach, the mini/less open sublay repair (MILOS) approach, and the endoscopic MILOS (EMILOS), allow retro-rectus mesh placement minimally invasively without traumatic fixation due to the autologous barrier between the mesh and the viscera, thereby reducing the risk of adhesions, visceral lesions, nerve damage, and post-op pain., After opening the rectus sheath, such as the MILOS procedure, the EMILOS operation proceeds with endoscopic dissection of the retromuscular space. EMILOS is particularly indicated in patients with abdominal diastasis, for instance this patient, as endoscopy allows better visual guidance for dissection of the retromuscular plane. However, studies comparing eTEP, MILOS, and EMILOS techniques with standard open and laparoscopic techniques are limited by short follow-up and debate over indications and contraindications. In addition, eTEP involves more dissection between abdominal wall layers and all techniques involve a longer operating time. Currently, MILOS allows the repair of hernias up to 20 cm, and EMILOS up to 30 cm, for instance in this patient, which is promising., However, randomized trials need to compare emerging with current techniques before their widespread adoption.
One limitation of this article is that records on the type and size of the mesh as well as the fixation method utilized in the primary operation are not available. In addition, hernia recurrence can take at least two years, making the one-year follow-up in this study too short.
Overall, mesh erosion carries significant consequences, occurring years after hernia surgery. Contributors include mesh type, fixation method, mesh migration, and mesh placement. Mesh registries and standardized reporting are crucial to study the problem and emerging solutions.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Medicare statistics item number reports. Available from: http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp. [Last accessed on2022 Jan 1].
Kokotovic D, Bisgaard T, Helgstrand F. Long-term recurrence and complications associated with elective incisional hernia repair. JAMA 2016;316:1575-82.
Hawn MT, Snyder CW, Graham LA, Gray SH, Finan KR, Vick CC. Long-term follow-up of technical outcomes for incisional hernia repair. J Am Coll Surg 2010;210:648-55, 655-7.
Kamarajah SK, Smart NJ, Daniels IR, Pinkney TD, Harries RL. Bioabsorbable mesh use in midline abdominal wall prophylaxis and repair achieving fascial closure: A cross-sectional review of stage of innovation. Hernia 2021;25:3-12.
Warren J, Desai SS, Boswell ND, Hancock BH, Abbad H, Ewing JA, et al
. Safety and efficacy of synthetic mesh for ventral hernia repair in a contaminated field. J Am Coll Surg 2020;230:405-13.
Alabi A, Haladu N, Scott N, Imamura M, Ahmed I, Ramsay G, Brazzelli M. Mesh fixation techniques for inguinal hernia repair: An overview of systematic reviews of randomised controlled trials. Hernia 2021;25. doi: 10.1007/s10029-021-02546-x
Fajardo R, Diaz F, Cabrera LF, Pedraza M. Acute abdomen in the centanary patient, mesh migration into the sigmoid colon after laparoscopic inguinal hernia repair (Tapp): A case report and review of literature. Int J Surg Case Rep 2020;66:334-7.
Stoppa R, Petit J, Abourachid H, Henry X, Duclaye C, Monchaux G, et al
. [Original procedure of groin hernia repair: Interposition without fixation of dacron tulle prosthesis by subperitoneal median approach]. Chirurgie 1973;99: 119-23.
Reinpold W, Schröder M, Berger C, Nehls J, Schröder A, Hukauf M, et al
. Mini- or less-open sublay operation (Milos): A new minimally invasive technique for the extraperitoneal mesh repair of incisional hernias. Ann Surg 2019;269:748-55.
Schwarz J, Reinpold W, Bittner R. Endoscopic mini/less open sublay technique (Emilos): A new technique for ventral hernia repair. Langenbecks Arch Surg 2017;402:173-80.
Department of General Surgery, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD 4102
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]