Laparoscopic Removal of an Infected Mesh Following TEP Procedure for Femoral Hernia with Omental Patch Closure of a Peritoneal Defect

Background

Mesh infection after inguinal hernia repair is a rare complication, accounting for 0.17% [1]. Mesh removal is recommended for mesh infection [2]. Laparoscopic mesh removal has been reported to be feasible and effective; however, details regarding peritoneal defect management, which often occurs following mesh removal, have been rarely described [3,4]. We report a case of mesh infection after fem-oral hernia repair using a totally extraperitoneal approach (TEP) and effective laparoscopic management of peritoneal defects after mesh removal.

Case Report

A 76-year-old woman underwent TEP hernia repair for a symptomatic right femoral hernia, as an elective (non-emergency) procedure. 3D Max® (Bard, USA), a prosthetic mesh, was fixed to the abdominal wall by tacker (CAPSURE®, Bard, USA). There was no contamination leading to mesh infection in the right groin during the first surgery. The operative time was 91 min. The patient was discharged on postoperative day 2 without complications. However, a month and a half later, she had right inguinal pain and swelling (Figure 1A). Plain computed tomography (CT) showed fluid collection in the right groin (Figure 1B). Although we suspected postoperative mesh infection, we initially opted for conservative management and a surgical approach when conservative management fails. Percutaneous drainage was performed for fluid collection, and purulent discharge was observed. Staphylococcus lugdunensis was detected in abscess cultures. Further, antibiotics (tazobactam/ piperacillin, 4.5 g I.V. 3 times daily) were administered for 4 days. Although her symptoms temporarily improved, the inguinal pain relapsed, and a purulent discharge from the right groin was observed (Figure 2A). Contrast-enhanced CT showed inflammation around the 3D Max® mesh and an abscess under the right groin (Figure 2B, 2C).

We decided to remove the infected mesh laparoscopically. A trocar was inserted, as shown in Figure 3A. The peritoneum was opened, and the infected mesh was approached. All tacks used for mesh fixation were removed as the screw was released, and the infected mesh was removed under the magnified view of a laparoscope (Figure 3B). After washing the infected peritoneal cavity, a Clio drain (6 mm; Sumitomo Bakelite, Japan) was inserted from the right port site into the preperitoneal cavity (Figure 3C). Peritoneal closure was impossible because of inflammation. Therefore, to prevent adhesions with tissues lacking peritoneal covering, which may have led to adhesive intestinal obstruction, we sutured the greater omentum to the peritoneum and covered the peritoneal defect (Figure 3D). Finally, debridement and open drainage of the purulent discharge were performed. The operative time was 250 min. Additionally, S. lugdunensis was confirmed in the culture of the infected mesh.

The postoperative course was uneventful, and the groin pain gradually improved. The patient was discharged on postoperative day 20. Thereafter, no recurrence of right femoral hernia or infection was observed in the 2-month follow-up.

Discussion

To the best of our knowledge, this case report is the first to describe a detailed procedure for laparoscopic salvage surgery for mesh infection after TEP approach. Although there are already some published case reports describing the laparoscopic approach for mesh infection management following hernia repair, the most important point in this report is how we managed the opened peritoneum [3,4]. In our case, we could not completely close the opened peritoneum. We are the first to report the use of a greater omentum patch for peritoneal defect closure.

Minimally invasive approaches, such as laparoscopic or robotic surgery, have been reported to be superior to open groin hernia repair regarding length of postoperative hospitalization, incidence of chronic pain, and postoperative infection [5,6]. Therefore, endovideosurgical and laparoscopic approaches, including TEP and transabdominal preperitoneal (TAPP) repair, respectively, have become common. At our institution, TEP approach is the standard procedure for treating groin hernias. Moreover, we use a non-absorbable tack (CAPSURE®, Bard, USA) for mesh fixation, although the usefulness of tissue glue and self-gripping mesh has been recently reported [7,8].

S. lugdunensis is estimated to be present in 30–50% of patients, mostly in the inguinal area, sometimes leading to skin, soft-tissue, and prosthetic object infections [9,10]. In this case, since the bacteria were detected in the culture of the removed mesh, the mesh may have been contaminated during TEP repair. To prevent mesh infection, the mesh should be inserted into the abdominal cavity, ensuring that it does not contact the inguinal skin.

Although mesh removal is the first choice for suspected mesh infection after hernia repair, we selected conservative treatment, including percutaneous drainage and antibiotic administration, because none of our surgeons had experienced mesh infection following TEP hernia repair [2]. Mesh removal should have been performed during the first treatment because the conservative treatment failed, as expected. In contrast, conservative management with negative-pressure wound therapy for mesh infection after hernia surgery has been reported [11]. Although we did not adopt this therapy and instead performed percutaneous drainage and antibiotic administration, this approach may be an option for mesh infection in the future.

Salvage surgery for mesh infections has several limitations that should be resolved. The first is how we approach the infected mesh, the second is whether to remove non-absorbable tacks used to fix the mesh, and finally, when abdominal wall or peritoneal defects occur after mesh removal, how we manage the situation. Regarding the approach to the infected mesh, we selected the non-open approach, that is, laparoscopic surgery (TAPP approach), because its usefulness has already been reported [3,4]. We could easily approach the preperitoneal space and remove the infected mesh after the peritoneum was opened. All the tacks were easily removed when the screw was released. Although the contamination of the peritoneal cavity may be a concern in the TAPP approach, we washed the peritoneal cavity after mesh removal and the patient experienced no complications, such as intraabdominal abscess, postoperatively. The laparoscopic approach was considered more advantageous compared with the open approach because we could reduce abdominal wall destruction when the infected mesh was dissected from the abdominal wall and safely preserve important anatomical structures, such as the inferior epigastric vessels and external iliac vessels, under the magnified view by laparoscopy.

The exposed preperitoneal space was not completely closed, as shown in Figure 3C. We were worried about adhesions with tissues lacking peritoneal covering. As mentioned above, we sutured the greater omentum to the abdominal wall to cover the exposed preperitoneal space. The greater omentum is effectively used in various surgical fields, including contaminated ones, other than gastrointestinal surgery, such as thoracic and cardiovascular surgeries [12,13]. In the present case, we closed the peritoneal defect using the greater omentum and the patient experienced no complications postoperatively. Regarding clinical situations associated with a contaminated surgical field and closure of the peritoneal defect, the use of omentum was effective. Further follow-up is needed to ascertain whether the greater omentum prevents adhesive small-bowel obstruction.

It remains controversial whether concurrent hernia repair is mandatory, including the method of its repair. Several options, such as the use of a biologic mesh or a biosynthetic material, autologous tissue coverage, and a primary closure are available [2,14–16]. However, the hernia recurrence rate, which accounts for 13–88%, after these procedures remains unsatisfactory. Nevertheless, Fawole et al reported that hernia recurrence after mesh removal is uncommon because of the fibrous reaction evoked due to it [17]. In our case, the hernia recurrence was not observed, and preoperative groin pain was completely resolved, although the postoperative follow-up duration (2 months) may be short. As suggested in a previous report, if femoral hernia recurrence occurs, an infrainguinal approach using plug mesh may be useful [18].

Conclusions

The patient experienced no relapse of femoral hernia and re-infection, and the groin pain was completely resolved. The laparoscopic approach for infected meshes after TEP or TAPP repair is preferable to the open approach. The use of a greater omen-tal patch is recommended for patients with peritoneal defects.