TECHNICAL REPORT
A Rare Case of Mesh Infection 3 Years After a Laparoscopic Totally Extraperitoneal (TEP) Inguinal Hernia Repair Anahita Jalilvand, MD,* Sharfi Sarker, MD, MPH,* and Piero M. Fisichella, MD, MBA, FACSw
Abstract: Late complications after a laparoscopic inguinal hernia repair are extremely rare and have only recently entered into the literature. One such late complication is mesh infection, of which there have been a handful of cases reported in the literature. Mesh infections occurring many years after inguinal hernia repairs are not only of significance because they are not well documented in the literature, and the pathogenesis and risk factors contributing to their development are not well understood. This report details a rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal inguinal hernia repair, describes our management of the condition, highlights the current options for management, and attempts to define its pathophysiology. Key Words: totally extraperitoneal (TEP) repair, inguinal hernia repair, mesh infection
(Surg Laparosc Endosc Percutan Tech 2015;25:e69–e71)
A
lthough complications, such as mesh infections, nerve injuries, and chronic postoperative pain, have been described for the laparoscopic repair, these occurrences have mostly been reported in the immediate postoperative period. Late complications after a laparoscopic inguinal hernia repair (LIHR) are extremely rare and have only recently entered into the literature. One such late complication is delayed mesh infection, of which there have been a handful of cases reported in the literature. Delayed mesh infection is very rare, with an estimated incidence of 0.1% to 0.2% after laparoscopic repair1–3 and can occur anytime postoperatively, even many years after the operation. This report details a rare case of mesh infection 3 years after a totally extraperitoneal (TEP) inguinal hernia repair, describes our management of the condition, highlights the current options for management, and attempts to define its pathophysiology.
symptomatic recurrence on the contralateral side. He was seen in clinic at our institution, and he agreed to a recurrent right inguinal hernia repair by a TEP approach. The operation was uncomplicated and straightforward. A 6 4-inch Parietex anatomic mesh (Covidien, Mansfield, MA), was used and a thin layer of a fibrin sealant (2 mL Tissel; Baxter, Westlake Village, CA) was sprayed using a cannula to secure the mesh in the preperitoneal place. The patient was discharged home the same day and returned to his activities 1 week after the operation. The patient did very well for 3 years without any complication. In 2013, he presented after he noticed a “pop” and an enlarging right inguinal bulge. In addition, he also experienced increasing fatigue, fevers and chills, and he lost approximately 30 lbs over the past 2 months. An abdominal computed tomography was obtained, revealing a multiloculated retroperitoneal fluid collection measuring 5.43.3 10.4 cm (Figs. 1, 2). He was admitted to the hospital, placed on IV piperacillin and tazobactam followed by percutaneous drainage of the retroperitoneal abscess. His antibiotic coverage was changed to ampicillin/sulbactam, as the cultured abscess fluid returned positive for Staphylococcus aureus. The goal of percutaneous drainage was to adequately drain the abscess cavity and reduce the inflammatory reaction in the groin in preparation for mesh removal and repair of the hernia defect. He underwent a colonoscopy to ascertain potential causes for the mesh infection. No lesions suspicious for malignancy were found on colonoscopic evaluation, although a mild cecal colitis was noted. The patient subsequently underwent elective excision of his right inguinal mesh, and repair of the hernia defect with biological mesh. During the operation, significant inflammation and edema was encountered during the dissection in the right inguinal area. The mesh was found correctly placed under the right rectus, with its inferomedial aspect embedded in the pubic bone. Once the mesh was completely removed without damaging
CASE REPORT A 78-year-old white male with hypertension, hyperlipidemia, former smoker who quit over 30 years before presentation, had bilateral open inguinal hernia repairs in his 20s. He developed a recurrent left inguinal hernia in 1999, which was treated with a laparoscopic transabdominal repair. In 2010, he experienced a Received for publication April 14, 2014; accepted July 22, 2014. From the *Department of Surgery, Loyola University Medical Center, Maywood, IL; and wDepartment of Surgery, Boston VA Healthcare System, Brigham and Women’s Hospital, Harvard Medical School, West Roxbury, MA. The authors declare no conflicts of interest. Reprints: Piero M. Fisichella, MD, MBA, FACS, Department of Surgery, Boston VA Healthcare System, Brigham and Women’s Hospital, Harvard Medical School, 1400 VFW Parkway (112), West Roxbury, MA 02132 (e-mail: piero.fi[email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
FIGURE 1. An abdominal/pelvic computed tomography with contrast revealed a large multiloculated retroperitoneal fluid collection measuring 5.4 3.3 10.4 cm collection in the right lower quadrant. Significant fat stranding and edema is noted within the layers of the abdominal musculature.
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Jalilvand et al
FIGURE 2. An abdominal/pelvic computed tomography with contrast revealed a large multiloculated retroperitoneal fluid collection measuring 5.4 3.3 10.4 cm collection in the right lower quadrant. Significant fat stranding and edema is noted within the layers of the abdominal musculature. the cord structures, a resulting 4 6 cm defect in the floor of the inguinal canal was closed with a biological mesh, AlloMax Surgical Graft (Davol Inc., Warwick, RI) and secured with 2-0 Prolene to the inguinal ligament, conjoint tendon, and internal oblique muscle. The wound was left open and a V.A.C. (KCI, San Antonio, TX) dressing was applied, with the goal of reducing the risk of seroma and infection. At 2-week follow-up, the patient’s incision was healing well. At 8-month follow-up, the patient was doing well without any hernia recurrence or wound complications.
DISCUSSION Although complications from the usage of the same synthetic mesh described in this report have been well documented, the majority of these occurrences have been reported as short-term complications. For example, Lepere and colleagues conducted a multicentric study comparing perioperative complications using Parietex mesh during TEP versus transabdominal pre-peritoneal (TAPP) inguinal hernia repair. Of 1972 cases studied, mesh infection was documented once in a TEP repair, accounting for an incidence rate of 0.2%. The mean follow-up was only 53 days.1 Similarly, a recent multicenter prospective study by Ramshaw and colleagues studied 495 patients who underwent TEP repair using Parietex mesh. They reported a 2.4% incidence of postoperative seroma formation and no cases of mesh infections, with a mean follow-up of 11 months.2 Late complications after LIHR have just recently begun emerging in the literature. A literature review that we conducted on the subject of delayed mesh infections after LIHR using PubMed revealed only a handful of these cases. In 1998, Foschi et al4 were the first to document delayed mesh infection 3 years following a TAPP inguinal hernia repair with polypropylene mesh placement. In 2011, Gukas and colleagues reported a case of an extensive mesh infection 5 years after bilateral laparoscopic TEP inguinal hernia repair in a 57-year-old male smoker. Both meshes were involved in the infection, which tracked into the anterior abdominal rectus sheath, the right and left paracolic gutter and pelvis, and the rectovesical pouch.5 The patient underwent emergent exploration along with a laparotomy, small bowel resection, and ileostomy. A similar case reported by Aravind et al6 in 2013 describes an infected
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Volume 25, Number 2, April 2015
seroma and mesh 6 years after a bilateral TEP inguinal hernia repair with polypropylene mesh. Although the overall incidence of delayed mesh infections is rare, the consequences of delayed mesh infections are noteworthy. Because such a relatively small number of late mesh infection have been reported, the underlying pathophysiology leading up to this complication has not been elucidated; although several theories have been proposed. One theory states that the inflammatory reaction surrounding the normal implantation of mesh is thought to account for its vulnerability to colonization by other inflammatory foci of infection present in other organs or systems.4,6,7 Examples might be intra-abdominal pathologies, such as colonic diverticulitis or malignancy, or an underlying lung infection in a long time smoker.5 Then, the inflammatory reaction surrounding the mesh in conjunction with the sporadic onset of such an infection is thought to account for the delay and unpredictable timing of this occurrence. Another theory proposes that mesh infections may be linked to postoperative seroma formation.6 As seroma is one of the most common complications of inguinal hernia repair, it is hypothesized that many subclinical seromas may be missed in the immediate postoperative period. As they become larger with time, there may be an increased risk of seroma infection leading to mesh infection. For this reason, Tamme et al3 propose placing a 20-F drain at the end of each repair to prevent seroma formation. A large retrospective study conducted by Tamme et al3 involving 5203 TEP hernia repairs over 7.5 years reported only 1 case of mesh infection (accounting for 0.02%), which required an anterior abdominal incision and antibiotics. The reduced rate of postoperative seroma formation is thought by Tamme et al3 to account for the very minimal incidence of late mesh infection reported in their study. Identifying the risk factors leading to the mesh infection experienced by our patient has proven to be more difficult. Although no lesions suspicious for malignancy were found on colonoscopic evaluation, mild cecal colitis was noted which hypothetically may have served as the initial source of infection. Preventative measures to eliminate the risk of delayed mesh infections have been suggested, but most of these have not been formally evaluated in randomized controlled trials. Our patient underwent mesh fixation with Tisseel fibrin sealant. A recent study in 2012 conducted by Campanelli et al8 comparing fibrin sealant and suture fixation over a 1-year period showed no statistical difference in wound healing complications between the 2 groups. A similar prospective randomized trial conducted by Lovisetto et al9 comparing tacks versus sealant fixation in TAPP inguinal hernia repair revealed no incidence of mesh infections in either group over a 1-year period. Although the follow-up periods of these studies are short, no evidence currently suggests a higher rate of mesh infection with fibrin sealant over a longer period of time. Although all reported cases of delayed mesh infection have been shown to cause severe complications, it is important to note that given its rarity, there is no effective screening test to reduce the risk of this occurrence. However, in patients with a history of inguinal hernia repair with mesh placement who develop signs of an infection, an enlarging inguinal bulge, constipation, weight loss, abdominal pain, and have radiographic evidence of retroperitoneal or inguinal abscess, a high index of suspicion for an infected mesh should be maintained.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
REFERENCES 1. Lepere M, Benchetrit S, Debaert M. A multicentric comparison of transabdominal versus totally extraperitoneal laparoscopic hernia repair using PARIETEX Meshes. JSLS. 2000;4:147–153. 2. Ramshaw B, Abiad F, Voeller G. Polyester (Parietex) mesh for total extraperitoneal laparoscopic inguinal hernia repair: initials experience in the United States. Surg Endosc. 2003;17:498–501. 3. Tamme C, Scheidbach H, Hampe C. Totally extraperitoneal endoscopic inguinal hernia repair (TEP). Surg Endosc. 2003;17:190–195. 4. Foschi D, Corsi F, Cellerino P. Late rejection of the mesh after laparoscopic hernia repair. Surg Endosc. 1998;12:455–457. 5. Gukas ID, Massouh F. Serious life-threatening complication 5 years after laparoscopic totally extraperitoneal hernia repair: case report and discussion of the literature. Hernia. 2011;15: 459–462.
Copyright
r
A Rare Case of Mesh Infection
6. Aravind B, Cook A. Intra-abdominal giant infected seroma following laparoscopic inguinal hernia repair. Hernia. 2013, PMID:24162134. 7. Mann DV, Prout J, Havranek E. Late-onset deep prosthetic infection following mesh repair of inguinal hernia. Am J Surg. 1998;176:12–14. 8. Campanelli G, Pascual MH, Hoeferlin A. Randomized, controlled, blinded trial of tisseel/tissucol for mesh fixation in patients undergoing lichtenstein technique for primary inguinal hernia repair: results of the TIMELI Trial. Ann Surg. 2012; 255:650–657. 9. Lovisetto F, Zonta S, Rota E. Use of human fibrin glue (Tissucol) versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty: a prospective, randomized study. Ann Surg. 2007;245:222–231.
2014 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
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A Rare Case of Mesh Infection 3 Years After a Laparoscopic Totally Extraperitoneal (TEP) Inguinal Hernia Repair Anahita Jalilvand, MD,* Sharfi Sarker, MD, MPH,* and Piero M. Fisichella, MD, MBA, FACSw
Abstract: Late complications after a laparoscopic inguinal hernia repair are extremely rare and have only recently entered into the literature. One such late complication is mesh infection, of which there have been a handful of cases reported in the literature. Mesh infections occurring many years after inguinal hernia repairs are not only of significance because they are not well documented in the literature, and the pathogenesis and risk factors contributing to their development are not well understood. This report details a rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal inguinal hernia repair, describes our management of the condition, highlights the current options for management, and attempts to define its pathophysiology. Key Words: totally extraperitoneal (TEP) repair, inguinal hernia repair, mesh infection
(Surg Laparosc Endosc Percutan Tech 2015;25:e69–e71)
A
lthough complications, such as mesh infections, nerve injuries, and chronic postoperative pain, have been described for the laparoscopic repair, these occurrences have mostly been reported in the immediate postoperative period. Late complications after a laparoscopic inguinal hernia repair (LIHR) are extremely rare and have only recently entered into the literature. One such late complication is delayed mesh infection, of which there have been a handful of cases reported in the literature. Delayed mesh infection is very rare, with an estimated incidence of 0.1% to 0.2% after laparoscopic repair1–3 and can occur anytime postoperatively, even many years after the operation. This report details a rare case of mesh infection 3 years after a totally extraperitoneal (TEP) inguinal hernia repair, describes our management of the condition, highlights the current options for management, and attempts to define its pathophysiology.
symptomatic recurrence on the contralateral side. He was seen in clinic at our institution, and he agreed to a recurrent right inguinal hernia repair by a TEP approach. The operation was uncomplicated and straightforward. A 6 4-inch Parietex anatomic mesh (Covidien, Mansfield, MA), was used and a thin layer of a fibrin sealant (2 mL Tissel; Baxter, Westlake Village, CA) was sprayed using a cannula to secure the mesh in the preperitoneal place. The patient was discharged home the same day and returned to his activities 1 week after the operation. The patient did very well for 3 years without any complication. In 2013, he presented after he noticed a “pop” and an enlarging right inguinal bulge. In addition, he also experienced increasing fatigue, fevers and chills, and he lost approximately 30 lbs over the past 2 months. An abdominal computed tomography was obtained, revealing a multiloculated retroperitoneal fluid collection measuring 5.43.3 10.4 cm (Figs. 1, 2). He was admitted to the hospital, placed on IV piperacillin and tazobactam followed by percutaneous drainage of the retroperitoneal abscess. His antibiotic coverage was changed to ampicillin/sulbactam, as the cultured abscess fluid returned positive for Staphylococcus aureus. The goal of percutaneous drainage was to adequately drain the abscess cavity and reduce the inflammatory reaction in the groin in preparation for mesh removal and repair of the hernia defect. He underwent a colonoscopy to ascertain potential causes for the mesh infection. No lesions suspicious for malignancy were found on colonoscopic evaluation, although a mild cecal colitis was noted. The patient subsequently underwent elective excision of his right inguinal mesh, and repair of the hernia defect with biological mesh. During the operation, significant inflammation and edema was encountered during the dissection in the right inguinal area. The mesh was found correctly placed under the right rectus, with its inferomedial aspect embedded in the pubic bone. Once the mesh was completely removed without damaging
CASE REPORT A 78-year-old white male with hypertension, hyperlipidemia, former smoker who quit over 30 years before presentation, had bilateral open inguinal hernia repairs in his 20s. He developed a recurrent left inguinal hernia in 1999, which was treated with a laparoscopic transabdominal repair. In 2010, he experienced a Received for publication April 14, 2014; accepted July 22, 2014. From the *Department of Surgery, Loyola University Medical Center, Maywood, IL; and wDepartment of Surgery, Boston VA Healthcare System, Brigham and Women’s Hospital, Harvard Medical School, West Roxbury, MA. The authors declare no conflicts of interest. Reprints: Piero M. Fisichella, MD, MBA, FACS, Department of Surgery, Boston VA Healthcare System, Brigham and Women’s Hospital, Harvard Medical School, 1400 VFW Parkway (112), West Roxbury, MA 02132 (e-mail: piero.fi[email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
FIGURE 1. An abdominal/pelvic computed tomography with contrast revealed a large multiloculated retroperitoneal fluid collection measuring 5.4 3.3 10.4 cm collection in the right lower quadrant. Significant fat stranding and edema is noted within the layers of the abdominal musculature.
Volume 25, Number 2, April 2015
www.surgical-laparoscopy.com |
e69
Surg Laparosc Endosc Percutan Tech
Jalilvand et al
FIGURE 2. An abdominal/pelvic computed tomography with contrast revealed a large multiloculated retroperitoneal fluid collection measuring 5.4 3.3 10.4 cm collection in the right lower quadrant. Significant fat stranding and edema is noted within the layers of the abdominal musculature. the cord structures, a resulting 4 6 cm defect in the floor of the inguinal canal was closed with a biological mesh, AlloMax Surgical Graft (Davol Inc., Warwick, RI) and secured with 2-0 Prolene to the inguinal ligament, conjoint tendon, and internal oblique muscle. The wound was left open and a V.A.C. (KCI, San Antonio, TX) dressing was applied, with the goal of reducing the risk of seroma and infection. At 2-week follow-up, the patient’s incision was healing well. At 8-month follow-up, the patient was doing well without any hernia recurrence or wound complications.
DISCUSSION Although complications from the usage of the same synthetic mesh described in this report have been well documented, the majority of these occurrences have been reported as short-term complications. For example, Lepere and colleagues conducted a multicentric study comparing perioperative complications using Parietex mesh during TEP versus transabdominal pre-peritoneal (TAPP) inguinal hernia repair. Of 1972 cases studied, mesh infection was documented once in a TEP repair, accounting for an incidence rate of 0.2%. The mean follow-up was only 53 days.1 Similarly, a recent multicenter prospective study by Ramshaw and colleagues studied 495 patients who underwent TEP repair using Parietex mesh. They reported a 2.4% incidence of postoperative seroma formation and no cases of mesh infections, with a mean follow-up of 11 months.2 Late complications after LIHR have just recently begun emerging in the literature. A literature review that we conducted on the subject of delayed mesh infections after LIHR using PubMed revealed only a handful of these cases. In 1998, Foschi et al4 were the first to document delayed mesh infection 3 years following a TAPP inguinal hernia repair with polypropylene mesh placement. In 2011, Gukas and colleagues reported a case of an extensive mesh infection 5 years after bilateral laparoscopic TEP inguinal hernia repair in a 57-year-old male smoker. Both meshes were involved in the infection, which tracked into the anterior abdominal rectus sheath, the right and left paracolic gutter and pelvis, and the rectovesical pouch.5 The patient underwent emergent exploration along with a laparotomy, small bowel resection, and ileostomy. A similar case reported by Aravind et al6 in 2013 describes an infected
e70 | www.surgical-laparoscopy.com
Volume 25, Number 2, April 2015
seroma and mesh 6 years after a bilateral TEP inguinal hernia repair with polypropylene mesh. Although the overall incidence of delayed mesh infections is rare, the consequences of delayed mesh infections are noteworthy. Because such a relatively small number of late mesh infection have been reported, the underlying pathophysiology leading up to this complication has not been elucidated; although several theories have been proposed. One theory states that the inflammatory reaction surrounding the normal implantation of mesh is thought to account for its vulnerability to colonization by other inflammatory foci of infection present in other organs or systems.4,6,7 Examples might be intra-abdominal pathologies, such as colonic diverticulitis or malignancy, or an underlying lung infection in a long time smoker.5 Then, the inflammatory reaction surrounding the mesh in conjunction with the sporadic onset of such an infection is thought to account for the delay and unpredictable timing of this occurrence. Another theory proposes that mesh infections may be linked to postoperative seroma formation.6 As seroma is one of the most common complications of inguinal hernia repair, it is hypothesized that many subclinical seromas may be missed in the immediate postoperative period. As they become larger with time, there may be an increased risk of seroma infection leading to mesh infection. For this reason, Tamme et al3 propose placing a 20-F drain at the end of each repair to prevent seroma formation. A large retrospective study conducted by Tamme et al3 involving 5203 TEP hernia repairs over 7.5 years reported only 1 case of mesh infection (accounting for 0.02%), which required an anterior abdominal incision and antibiotics. The reduced rate of postoperative seroma formation is thought by Tamme et al3 to account for the very minimal incidence of late mesh infection reported in their study. Identifying the risk factors leading to the mesh infection experienced by our patient has proven to be more difficult. Although no lesions suspicious for malignancy were found on colonoscopic evaluation, mild cecal colitis was noted which hypothetically may have served as the initial source of infection. Preventative measures to eliminate the risk of delayed mesh infections have been suggested, but most of these have not been formally evaluated in randomized controlled trials. Our patient underwent mesh fixation with Tisseel fibrin sealant. A recent study in 2012 conducted by Campanelli et al8 comparing fibrin sealant and suture fixation over a 1-year period showed no statistical difference in wound healing complications between the 2 groups. A similar prospective randomized trial conducted by Lovisetto et al9 comparing tacks versus sealant fixation in TAPP inguinal hernia repair revealed no incidence of mesh infections in either group over a 1-year period. Although the follow-up periods of these studies are short, no evidence currently suggests a higher rate of mesh infection with fibrin sealant over a longer period of time. Although all reported cases of delayed mesh infection have been shown to cause severe complications, it is important to note that given its rarity, there is no effective screening test to reduce the risk of this occurrence. However, in patients with a history of inguinal hernia repair with mesh placement who develop signs of an infection, an enlarging inguinal bulge, constipation, weight loss, abdominal pain, and have radiographic evidence of retroperitoneal or inguinal abscess, a high index of suspicion for an infected mesh should be maintained.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
REFERENCES 1. Lepere M, Benchetrit S, Debaert M. A multicentric comparison of transabdominal versus totally extraperitoneal laparoscopic hernia repair using PARIETEX Meshes. JSLS. 2000;4:147–153. 2. Ramshaw B, Abiad F, Voeller G. Polyester (Parietex) mesh for total extraperitoneal laparoscopic inguinal hernia repair: initials experience in the United States. Surg Endosc. 2003;17:498–501. 3. Tamme C, Scheidbach H, Hampe C. Totally extraperitoneal endoscopic inguinal hernia repair (TEP). Surg Endosc. 2003;17:190–195. 4. Foschi D, Corsi F, Cellerino P. Late rejection of the mesh after laparoscopic hernia repair. Surg Endosc. 1998;12:455–457. 5. Gukas ID, Massouh F. Serious life-threatening complication 5 years after laparoscopic totally extraperitoneal hernia repair: case report and discussion of the literature. Hernia. 2011;15: 459–462.
Copyright
r
A Rare Case of Mesh Infection
6. Aravind B, Cook A. Intra-abdominal giant infected seroma following laparoscopic inguinal hernia repair. Hernia. 2013, PMID:24162134. 7. Mann DV, Prout J, Havranek E. Late-onset deep prosthetic infection following mesh repair of inguinal hernia. Am J Surg. 1998;176:12–14. 8. Campanelli G, Pascual MH, Hoeferlin A. Randomized, controlled, blinded trial of tisseel/tissucol for mesh fixation in patients undergoing lichtenstein technique for primary inguinal hernia repair: results of the TIMELI Trial. Ann Surg. 2012; 255:650–657. 9. Lovisetto F, Zonta S, Rota E. Use of human fibrin glue (Tissucol) versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty: a prospective, randomized study. Ann Surg. 2007;245:222–231.
2014 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
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