|Year : 2014 | Volume
| Issue : 2 | Page : 107-110
Late ileocutaneous fistula due to onlay mesh fixation after incisional hernia repair
Varun Raju Thirumalagiri, Ramakrishna Satwalekar, Ramachandra Polisetti, Tokala Hemachandra
Department of Surgery, Durgabai-Deshmukh Hospital and Research Center, Vidyanagar, Hyderabad, India
|Date of Web Publication||20-Jun-2014|
Varun Raju Thirumalagiri
Department of Surgery, Durgabai-Deshmukh Hospital and Research Center, Vidyanagar, Hyderabad - 500 044
Source of Support: None, Conflict of Interest: None
It is a well-known established fact about the low recurrence rate after mesh repair as compared with anatomical repair of the incisional hernia. Hernioplasty with polypropylene onlay fixation is now widely popular all over the world and being practiced routinely in many centers. This is a case of ileocutaneous fistula that occurred lately due to a stitch (polypropylene) gone through the underlying small bowel wall at the time of previous onlay mesh repair after a long postoperative gap. Although many techniques were described (open and laparoscopic) for the mesh fixation to the abdominal wall, in cases of gross obesity with thinned out abdominal musculature, extreme care must be taken to fix the mesh to the anterior abdominal wall for prevention of rare delayed postoperative complications. Different techniques are discussed to prevent the above said complication.
Keywords: Enterocutaneous fistula, ileocutaneous, incisional hernia, late presentation, onlay polypropylene mesh repair
|How to cite this article:|
Thirumalagiri VR, Satwalekar R, Polisetti R, Hemachandra T. Late ileocutaneous fistula due to onlay mesh fixation after incisional hernia repair. J NTR Univ Health Sci 2014;3:107-10
|How to cite this URL:|
Thirumalagiri VR, Satwalekar R, Polisetti R, Hemachandra T. Late ileocutaneous fistula due to onlay mesh fixation after incisional hernia repair. J NTR Univ Health Sci [serial online] 2014 [cited 2020 Jan 18];3:107-10. Available from: http://www.jdrntruhs.org/text.asp?2014/3/2/107/134851
| Introduction|| |
About 1-19% of patients commonly develop incisional hernia following an abdominal surgery. Anatomical repair of the primary surgery has shown up to 46% of recurrence due to the development of tension over the suture line with the time. Tension-free mesh repair especially onlay technique has lowered the reported recurrence to between 0% and 10%. Complications following mesh repair have decreased with the usage of monofilament polypropylene mesh in comparison to the usage of metallic mesh and other materials in the history of the mesh concept. Serious complications have been observed in small percentage of patients in whom prosthetic material was used for incisional hernia repair. Complications commonly observed are, wound infection, seroma collection, delayed wound healing, sinus formation, mesh migration, erosion of the mesh into the adjacent structures including the intestine, enterocutaneous fistula, intestinal obstruction, and recurrence of ventral hernia. In the literature, many techniques are described to prevent the various complications including late fistula formation, such as laparoscopic guidance for the open onlay mesh fixation.
| Case report|| |
A 65-year-old obese lady presented to us with the clinical diagnosis of an acute anterior lower abdominal wall abscess. After clinical examination and workup with the appropriate investigations, incision and drainage of the abscess was done under spinal anesthesia. Wound healed completely by 1½ months after the surgery. In the past she underwent an open incisional hernia surgery with the technique of onlay polypropylene mesh repair. After 2½ years of postoperative period, she presented to us with an acute abscess underneath the transverse scar of the previous surgery. Multiple episodes of local abscesses with spontaneous ruptures and healing by aseptic dressings and appropriate antibiotics have led us to a conclusion of dealing a case of chronic sinus on a scar of previous incisional hernia mesh repair [Figure 1]. Sinogram was suggestive of enterocutaneous fistula [Figure 2]. Magnetic resonance imaging was done for the exact anatomical details of the fistulous tract [Figure 3]. We discussed the clinical situation, outcomes, and management options with the patient. Preoperative workup was done well with the consultations and anesthetist checkups. Open surgery (laparotomy + fistulectomy + enterotomy + closure) was done under spinal anesthesia [Figure 4], [Figure 5], [Figure 6], [Figure 7].
|Figure 4: Transverse incision with an infant feeding tube as a guide in the fistulous tract|
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|Figure 7: After excision of the tract enterotomy and primary closure done in two layers|
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Prolene stitch anchoring the wall of ileal loop causing the fistulous tract was demonstrated. Excised specimen histopathologically has reported no specific infectious etiology.
| Discussion|| |
Small incisional hernias with good abdominal wall tone may be managed with anatomical repair, but larger ones are best managed with the prosthetic material support. Polypropylene mesh and other varieties of materials are popularly being used in open or laparoscopic methods for the management of incisional hernias. Prosthetic mesh repair is associated with lower recurrence rate but a higher incidence of complications. The most serious complication, though fortunately rare, is the development of enterocutaneous fistula. , The incidence of enterocutaneous fistula due to prosthetic mesh is higher in subfacial (5.2%) than in onlay (2.6%) position.  Mesh may be positioned in three ways: Onlay, sublay (preperitoneal), and intraperitoneal.  Intraperitoneal mesh placement may cause dense adhesions to the bowel, mesh migration, mesh erosion into adjacent anatomical structures, and enterocutaneous fistulas. ,
Infection is the most devastating complication associated with implantation of prosthetic materials.  Basoglu et al.,  mentioned that contact between mesh and the bowel should be avoided to prevent complications such as enterocutaneous fistulas. Burger and colleagues reported 3% incidence of enterocutaneous fistula and 5% of patients had sinus tract after mesh repair.  Leber et al.,  reported a 3.5% incidence of enterocutaneous fistula in their study. Onlay mesh fixation is commonly done with multiple anchoring prolene stitches. Depth perception to put the anchoring stitch depends upon the thickness of the abdominal wall musculature, and the experience of the surgeon. Unrecognized bowel injury due to the prolene stitch anchoring it to the posterior abdominal wall can lead to the necrosis of the wall and may result in fistula formation. Basoglu emphasized the need for peritoneal or omentum coverage for prevention of bowel contact to the mesh.  The technique described by Khaira et al., provides an additional barrier of rectus sheath or aponeurosis between the mesh and the hernia sac and also reduces the risk of bowel injury during mesh fixation.  In our case, previous surgery onlay mesh fixation led the bowel injury and formed a localized fistula without peritoneal contamination. The discharge was not feculent as it involved a very small circumference of the ileum. Two similar cases were reported by Acar et al.,  and Sistla et al.  The methods that are suggested widely to prevent the bowel injury during onlay mesh fixation are (1). Placement of the omentun over the bowel loops before closing the laparotomy opening. (2). Peritoneum is always closed. (3). Under laparoscopic guidance with a 5-mm telescope, onlay open mesh fixation can be performed safely without injuring the wall of a bowel loop.
| Conclusion|| |
Obese patients with thinned out abdominal muscular wall may give difficult depth perception for a surgeon to do on-lay mesh repair without causing injury to the underlying bowel loops. Some stitches may go into the wall of the bowel while repairing the same. Fistula formation is an issue to be prevented and solved with proper investigations and counseling in an aim to solve the problem with some preventive guidelines noted in the literature. Under Laparoscopic guidance, this rare mechanism of complication can be safely prevented.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]