Selected Articles from the
Journal Abdominal Surgery

This article originally appeared in the Spring, 2007 issue of the Journal.

Unexpected complication of Ventral hernia repair

Amala Chirumamilla, MBBS,
Internal Medicine resident,
University of Buffalo, New York.

Angelo C. Rizzo, D.O.
Attending In Department of Internal Medicine,
University of Buffalo, Buffalo, New York.

Contact address:
Amala Chirumamilla,
25 Garden Village drive #4,
Buffalo, NY, 14227.
Email: dramala@adelphia.net.
Phone: 716-668-3659
Fax: 716-668-3659

ABSTRACT
51 years old patient with chief complaint of worsening left thigh pain and feeling a moving object at the site, who was found to have migrated part of kugel mesh circle 12 x 12 cm after 5 years of ventral hernia repair. This complication is treated and the reason behind it is discussed.

INTRODUCTION
Major known long term complications of ventral hernia repair are chronic infections, sinus tract, small bowel obstruction, enterocutaneous fistula, recurrence of ventral hernia. We are describing in this case report a rare complication of ventral hernia repair with Kugel circle 12 X 12 cm (Figure 1).

CASE REPORT
History of present illness: Patient is 51 years old white female with a history of ventral hernia repair in 2001 presented with a 2 weeks history of excruciating left thigh pain. Pain started suddenly at rest, sharp in quality, increasing in intensity since onset and gets worse on movement of the limb. Pt. denies fever, chills; and trauma to the site. She noticed a red ring on her left thigh with a feeling of moving object below the skin for 2 days (Figure: 2).

Past medical history: Hypertension, Chronic obstructive pulmonary disease, depression, anxiety, arthritis. Past surgical history: Hysterectomy with Bilateral salpingo- ophorectomy, cholecystectomy, laparoscopic vein stripping of legs, ventral hernia repair with kugel 12 X 12 cm in 2001, and recurrence of ventral hernia with in a year. Social History: smoker 1PPD for 30 years, occasional alcohol use.

Allergies: No known drug allergies. Vitals: T-97.5, BP- 132/80, RR-12, PR-84. Physical Exam: Patient is well nourished and obese female appeared to be in acute distress due to pain. HEENT- pupils are round, equal and reactive, Lungs- Clear to auscultation, Heart- S1, S2 heard with no murmurs,

Abdomen: post surgical scar in the infra umbilical area, and right upper quadrant, soft, nontender, bowel sounds present in all four quadrants.

Extremities: Left thigh- 6 cm diameter ecchymotic area at the periphery and clear at the center on the medial aspect of her left thigh. On stretching of her skin there was sharp body at the center which was mobile and tender on palpation. All four extremities have normal pulses and no edema.

Figure1: Kugel Circle 12 X 12 cm

Figure2: Reproduction of the area involved

Neurologic exam: No focal deficits.

Clinically the evolution of pregnancy was done without any problems and the patient had no history of special tenderness related to the cyst lesions.

She gives history of caesarian section 15 years ago for fetal stress—and was operated for liver hydatid cyst 22 years ago.

The patient was prepared for the 2nd caesarian section and surgical treatment of hydatid cysts.

1st Operative time:Caesarian section:

Laparotomy through the previous incision for Caesarian section was performed, she delivered a healthy male baby weighing 4 kg.

2nd Operative time: Surgical removal of two hydatid cysts

The first one was intraperitoneal about 9 cm of diameter attached to the omentum. It was completely removed. (Figure 2)

There were no other intraperitonal localizations.

The second one was intra uterine measuring about 10 cm of diameter localized at the posterior side of the uterus. After puncture and suction of the hydatid fluid with daughter cysts, we sterilized the cyst’s cavity with hydrogen peroxide (H2O2 ,10 volumes) for 15 mn. (Figure 3a)

Removal of the wall of the hydatid cyst was completely done with closure of the uterine muscle with two layers. (Figure3c)

The left adenexia was attached to the cyst’s wall and the ligation of bilateral adenexia was performed (two partners were informed before surgery and they give thief consent).

Patient had a smooth post operative course and she was discharged with her baby in good condition. She was followed in surgery OPD by ultrasound examination; there were no more recurrence of hydatid cyst after 8 months of follow-up.

Albendazole treatment was started with a dose of 10mg/kg twice daily; two cycles of 28 days each, separated by 15 days of rest,were prescribed.

INTERVENTION
Area over the left thigh was prepped with alcohol. Local anesthetic 2% lidocaine was injected at the center, close to the moving body. After a superficial incision, end of a wire like foreign body was seen. It was slowly pulled out and a semicircular wire approximately 10cm in diameter was retrieved from the site (Figure: 3). The wire had close resemblance with a part of a hernia repair mesh There was minimal bleeding which stopped with pressure for two minutes after removal of the wire. Pain was instantly relieved.Wire like foreign body, was sent for pathology. Culture was negative. Surgeon was notified about the complication, and patient is being followed up closely by him to watch for further complications.

DISCUSSION
There was a FDA recall on April 3rd 2006 for ventral hernia repair devices – due to the potential for breakage of the “Memory recoil ring” under the stress of placement into the intraabdominal space, leading to bowel perforation and/or chronic enteric fistulae(1) Recalled repair devices included Bard composix kugel mesh patch -oval, large oval and large circle products. Patients who have received one of the recalled devices are told to seek immediate medical attention for unexplained or persistent abdominal pain, fever, tenderness at the implant site, or other unusual symptoms potentially related to ring breakage.

Cause of the complication presented in this case report is most probably due to mesh breakage and subcutaneous migration of the mesh part to the groin. Actual route of migration is not clear. During migration or during removal of the wire there is a potential to puncture or damage blood vessels causing severe bleed, which needs to be watched for carefully.

CONCLUSION
Patient with a mesh, especially with a recalled mesh for hernia repair should be educated about unusual complications along with usual complications which will result in early medical attention and intervention. Surgeons and internists should watch for unexpected migration of parts of mesh to lower extremities.

Figure1 (above left) Kugel Circle 12 X 12 cm Figure2 (above right) Reproduction of the area involved

Figure3 Part of Mesh retrieved from the left thigh of the patient.5

REFERENCE
1. MEDWATCH, adverse event reporting news: April 18, 2006-page 11.