A CHALLENGING CASE OF MANAGEMENT OF AN INFECTED MESH WITH LAPAROSCOPY, ADHESIOLYSIS AND REMOVAL OF THE MESH

Abstract

Abstract Aim To present a challenging case of an infected mesh in an obese patient managed with a combination of laparoscopy and open incision. Material and Methods An 57-year-old woman with diabetes type 2, obstructive sleep apnoea requiring Continued Positive Airway Pressure (CPAP) and a BMI of 43 presented to be seen in the outpatient clinic. Her visits were related to a infected mesh in her right upper quadrant of the abdomen as a result of a laparoscopic repair of incisional hernia post open cholecystectomy 13 years ago. The CT scan confirmed an infected mesh. A laparoscopy approach was used initially. Insufflation: Optic trocar COz 17 mmHg (left paramedian line). Ports: Leftt 10 mm, 2 × 5 mm LUQ and lower epigastric (midline). Findings: Laparoscopy: Adhesions of the omentum with the anterior abdominal wall, Cirrhotic liver, hepatic flexure below the area of the infected mesh but without any obvious colonic fistula. Open incision for fistulectomy: Long thick tract leading to preperitoneal space. Large cavity containing an infected mesh 15 × 15 polypropylene mesh. Metallic tacks present in the cavity. Procedure Adhesiolysis. Findings as above. Simultaneously laparoscopy and open exploration of the area of the fistula was performed with a surgeon on each side. Fistula was removed intact. A preperitoneal cavity was found which was the source of infection. Mesh was removed intact with tacks on. Sent for micro. Very good wash of the cavity with betadine. Exploration laparoscopically. Hepatic flexure was below the area of the infected mesh. As there was a suspicious area which might corresponded to a colonic fistula, further adhesiolysis was performed. The hepatic flexure was mobilised making sure that there was no bowel involvement. In order to maintain bowel wall and avoid injury, an area of the peritoneum was left on the bowel. Right colon was checked for injury – negative. Peritoneal defect was closed with 1 prolene (× 2) interrupted sutures with endoclose device. A 30 Fr Robinson's drain was left in the Rt paracolic gutter via the lower 5 mm port. Exsuflation of COz, extraction of trocars. Closure of the anterior abdominal wall with J PDS interrupted. 14Fr Redivas in the subcutaneous tissue. Results The patient's postoperative course was uneventful. She was discharged the 5th post operative day. At 3 months follow-up the patient is well and asymptomatic with a small induration of the skin in the area of the previous infection. Conclusion Mesh infection is a devastating complication. A surgeon with an interest and experience in abdominal wall surgery can offer a safe and efficient approach to these cases.