Mesh plug erosion into the small intestine after inguinal hernia repair: A case report

lNTRODUCTlON

In 1974, Lichtenstein reported using a piece of mesh rolled into a cylindrical shape to form a plug for the repair of femoral and recurrent inguinal hernias[1]. Gilbert changed the shape of the mesh plug (MP)into an umbrella or a cone to keep the MP fixed to the anterior abdominal wall to prevent slippage. In 1989, Rutkow repaired a Gilbert type III hernia on the basis of Gilbert’s approach by discontinuous suture of the MP fixed to the edge of a dilated internal ring. Inguinal hernia repair (IHR) using an MP reduced the recurrence rate to 0.1% and became one of the most widely used approaches for IHR[2].However, as the implanted MP is a foreign body, it is prone to infection, degeneration, shrinkage,migration, and erosion[3-5].

Mesh erosion is a term frequently used in the literature to describe any invasion of an organ by an entire or partial piece of mesh[3]. The sigmoid colon, urinary bladder and small bowel are the three most common sites of erosion. Rectal bleeding, colocutaneous fistula and sigmoiditis are the most frequent clinical indicators of digestive tract involvement; recurrent urinary tract infection and hematuria represent the most common symptoms of mesh-related bladder complications[5]. In recent years, with the increased understanding of postoperative complications, MP erosion into the intraabdominal organs has been a cause for concern among surgeons. Herein, we report a rare case of MP erosion into the small intestine to improve the knowledge of surgeons regarding this complication.

選修課作為核心課程的必要補(bǔ)充，也起著相當(dāng)重要的作用，參考《高等學(xué)校商務(wù)英語(yǔ)專業(yè)本科教學(xué)要求》，適合在獨(dú)立學(xué)院開設(shè)的商務(wù)英語(yǔ)專業(yè)選修課如表3所示。

CASE PRESENTATlON

Chief complaints

MP erosion into the intra-abdominal organs is a rare but serious long-term complication after IHR that can lead to aggravation of symptoms if not treated promptly. In a review of the literature from 2000 to 2021, 19 cases of complications related to MP erosion into the intestines were reported (Supplementary Table 1). In this case, MP erosion could have led to small bowel perforation without immediate intervention and was life-threatening.

History of present illness

表3結(jié)果顯示：在概念表征的四個(gè)水平中，學(xué)生的平均分與滿分之間具有顯著差異，由此可說(shuō)明學(xué)生的四個(gè)水平均較弱，并且內(nèi)外表征水平均沒(méi)有相關(guān)性，可知學(xué)生不善于將內(nèi)部表征外顯化。

History of past illness

He had a surgical history of right open IHR and partial thyroidectomy performed 20 years and 15 years ago, respectively.

MP erosion is a rare and long-term complication of IHR that can cause severe problems. It is difficult to diagnose MP erosion because there are no obvious specific clinical manifestations, and surgery is often needed for confirmation. MP erosion should also be included in the differential diagnosis of patients with a history of inguinal hernia repair who present with abdominal pain and the need for longer follow-up to detect MP erosion. Surgeons should aim to reduce the risk of such complications and improve their awareness of and ability to predict patients at high risk for MP erosion after IHR. The selection of appropriate repair materials, standardized surgical procedures, and maintenance of peritoneal integrity are important ways to prevent MP erosion. When MP erosion into the small intestine and intra-abdominal organs is diagnosed, the most effective treatment is removal of the mesh and resection or repair of the involved organs.

Personal and family history

He performed light work and did not smoke.

Physical examination

MP erosion is often accompanied by MP migration. As described by Agrawal[6], mesh migration after IHR may be classified primarily as mechanical or secondarily due to the erosion of surrounding tissue. Primary mechanical migration mainly refers to the displacement of the MP along the original anatomical space that offers the least resistance and is likely caused by inadequate fixation or external displacing forces. Secondary migration refers to the adjacent or distant migration of tissue structure across anatomical levels owing to the erosion and destruction of tissue structure caused by foreign body reaction between the MP and tissue.

Laboratory examinations

The laboratory examinations included assessment of tumor markers (alpha fetoprotein, carcinoembryonic antigen, carbohydrate antigen [CA] 125, CA15-3, CA19-9, and CA72-4); routine tests for blood and urine biochemistry; and stool tests. All test results were normal.

Imaging examinations

Ultrasonography identified a locally discontinuous band of strong echo in the abdominal wall of the right inguinal area. An inhomogeneous echo mass (dimensions: 3.9 cm × 1.5 cm) was detected on its deep surface (Figure 1). A weak blood flow signal was detected within the masscolor Doppler flow imaging. Computed tomography revealed a circinate high-density image with a short segmental thickening of the ileum stuck to the abdominal wall, and no evidence of recurrent inguinal hernia(Figure 2).

FlNAL DlAGNOSlS

MP erosion into the small intestine was diagnosed based on the reported clinical symptoms, laparoscopic abdominal exploration and postoperative pathology.

總之，泉州碳九事件折射出了當(dāng)?shù)卣块T公信力缺失，為全社會(huì)敲響了警鐘。企業(yè)固然有逃避責(zé)任和處罰的動(dòng)力，但作為政府部門，應(yīng)著眼于加強(qiáng)公信力建設(shè)，建立透明化的信息發(fā)布機(jī)制，依法對(duì)涉事企業(yè)進(jìn)行懲戒，并善于總結(jié)經(jīng)驗(yàn)教訓(xùn)，才能獲取普通大眾的更多理解和支持，為促進(jìn)經(jīng)濟(jì)發(fā)展創(chuàng)造良好的氛圍，凝聚全社會(huì)的力量，提升經(jīng)濟(jì)發(fā)展質(zhì)量。

TREATMENT

Laparoscopic abdominal exploration confirmed adhesion of the middle segmental portion of the ileal loop to the right inguinal abdominal wall (Figure 3A); the rest of the small intestine was normal. Further exploration revealed migration of the polypropylene MP into the intraperitoneal cavity and formation of granulation tissue around the plug, which eroded the ileum (Figure 3B). The internal ring was 1.0 cm in diameter, but no hernia sac was found (Figure 3C). There was no leakage of intestinal fluid at the site of erosion, thus we did not consider that there was a perforation of the intestine. Based on the findings of the preoperative ultrasound, we considered the MP method used previously to be responsible for the patient’s current complaints and complications. The flat mesh was in the correct position and did not need to be removed. Partial resection of the ileum, including the MP and end-to-side anastomosis with an anastomat, was performed. The dilated internal ring was repaired by a direct continuous suture of the surrounding peritoneum. Specimen examination revealed erosion of the iliac wall from the MP(Figure 3D). Postoperative pathology showed chronic inflammatory changes in the mucosa of the small intestine, with focal granulomatous tissue formation and focal abscess in the serosa (Figure 4).

In terms of the time to event, the complication in this case occurred 20 years after IHR, which shows that MP erosion is a long-term and chronic process. Based on anatomical considerations, a left-sided MP is more likely to involve the sigmoid colon, while a right-sided MP more frequently involves the small intestine or cecum. The three most vulnerable organs are the sigmoid colon, small intestine, and bladder. The clinical manifestations of an eroded sigmoid colon are hematochezia, colocutaneous fistula,and abdominal pain; of an eroded small intestine is intestinal obstruction[8]; and of an eroded bladder is hematuria[5].

OUTCOME AND FOLLOW-UP

The postoperative course of the patient was uneventful, and he was well at the 6-mo follow-up. There was no evidence of relapse of postoperative hernia.

DlSCUSSlON

A 50-year-old man (BMI of 24.3 kg/m) was referred to the Department of General Surgery in January 2021 with the complaint of abdominal pain in the right lower quadrant.

The timescale from previous IHR to the appearance of clinical symptoms (time to event) was from 10 days to 26 years, with a median of 6.3 years[5]. Given the long time since the previous surgery, patients typically tend to go to a different hospital than the one where they first underwent IHR. This could explain why the follow-up data in previous studies only considered factors such as hernia recurrence,chronic pain, and foreign body sensation and not long-term complications. The clinical presentation is not a characteristic of MP erosion, which makes it difficult to relate to the previous IHR, and the followup evaluation may neglect these details and consider it another new disease. MP erosion may be found more frequently in some large centers than reported in the literature, but because of medical-legal issues and authors' indifference or lack of awareness, the true rate could be underestimated.

Physical examination showed only tenderness in the right lower abdomen near the groin. There were no signs of peritonitis or reports of vomiting and fever.

It is still unclear whether a relationship exists between MP migration and the method used to fix the mesh. However, many studies have shown that there is no difference in hernia recurrence between fixed and unfixed mesh in either open or endoscopic surgery[7]. Unfortunately, most of the literature on MP migration did not describe the fixation method during anterior IHR. Therefore, we could not infer its effect on MP migration. Perhaps, future reports focusing on this aspect will help to understand this phenomenon.

9月1日，山東重工黨委書記譚旭光擔(dān)任中國(guó)重汽董事長(zhǎng)兼黨委書記。2006年，濰柴與中國(guó)重汽分家。2009年，濰柴動(dòng)力、山工集團(tuán)、山東汽車工業(yè)集團(tuán)組建成立山東重工集團(tuán)。2018年8月，中通客車的實(shí)際控制人山東交通工業(yè)集團(tuán)劃轉(zhuǎn)至山東重工集團(tuán)。一代企業(yè)家的奮斗拼搏，幾屆政府的強(qiáng)力意志，無(wú)數(shù)產(chǎn)業(yè)工人的技術(shù)愿景，分分合合，波瀾壯闊，中國(guó)制造的路徑與方向在這12年間從模糊到清晰，大國(guó)重器的愿景浮出水面，成為一個(gè)國(guó)家的產(chǎn)業(yè)共識(shí)。

We believe that the possible causes of our patient’s complication are as follows: (1) The peritoneum was damaged during the intraoperative separation of the preperitoneal space or the hernia sac, without defects of the peritoneum being detected, and the MP adhered to the internal organs through the peritoneum; (2) Even if the peritoneum was intact, the conical design of the MP and long-term direct contact with the peritoneum could have easily caused peritoneal erosion; and (3) Polypropylene developed significantly more adhesions[9], and erosion was related to the production process of the MP and the static pressure between the MP and tissue[10].

To avoid MP erosion, attention should be given to the following aspects: (1) The integrity of the peritoneum should be maintained when separating the hernia sac and preperitoneal space, if a peritoneal defect is found, the defect should be repaired immediately; and (2) The MP should fit the hernia ring. If it is too small, the effectiveness of the IHR is not guaranteed. In contrast, if the MP is too large and the hernia sac is relatively small, this can lead to excessive tension between the MP and surrounding tissue, in which case MP erosion into the peritoneum may be exacerbated. To prevent this,the MP should be properly trimmed to ensure that it has a certain degree of mobility.

Removal of the mesh and resection or repair of the involved organs were required in 96% of cases of MP erosion[5]. Is there a recurrence of IHR after MP removal? A previous study showed that there were more fibroblasts and scar tissue in the area around the mesh due to inflammatory intervention and fibroblast immersion[11]. If there is sufficient fibrous scar tissue, the hernia is unlikely to recur.

CONCLUSlON

X-射線晶體衍射分析儀(XRD)，荷蘭PANalytical公司，PANalytical X'pert Pro型。

The patient’s symptoms started 2 d previously with abdominal pain in the right lower quadrant, which had worsened in the last 2 h.

FOOTNOTES

Χie TH and Jin ΧS contributed to the drafting of the manuscript and revising the final draft;Wang Q and Ha SN contributed to the acquisition of data and revising the final draft; Cheng SJ, Niu Z, Ren ΧΧ and Sun Q contributed to the investigation and interpretation of the data; all authors have read and approved the manuscript.

the Medical Science Research Project of Hebei Provincial Health Commission, No. 20211642; and Key Research and Development Project of Hebei Province, No.21377773D.

Written consent for publication was acquired from the patient, and the signed consent will be provided upon request.

The authors declare that they have no competing interests.

當(dāng)然，低劑量螺旋CT作為肺結(jié)節(jié)的篩查也存在一些問(wèn)題。首先，結(jié)節(jié)的發(fā)現(xiàn)和分析需要有經(jīng)驗(yàn)的醫(yī)師仔細(xì)觀察，這其中存在著診斷水平的要求，所以需要副主任以上職稱的醫(yī)師進(jìn)行讀片，并且配置可以做多平面重建的工作站，這樣可以增加結(jié)節(jié)分析的準(zhǔn)確性和檢出率。其次，低劑量CT檢查發(fā)現(xiàn)結(jié)節(jié)后的跟蹤隨訪機(jī)制以及檢查者的配合需要完善、正確引導(dǎo)。另外，多排螺旋CT是必需的，16排以上的螺旋CT更好，因?yàn)閽呙杷俣瓤欤飨蛲裕嗥矫嬷亟▓D像不失真。目前國(guó)內(nèi)外專家對(duì)于低劑量CT掃描用于篩查發(fā)現(xiàn)肺內(nèi)陽(yáng)性結(jié)節(jié)的定義和處理意見還沒(méi)達(dá)到完全的統(tǒng)一，需要專家們的共同努力，給出一個(gè)標(biāo)準(zhǔn)指導(dǎo)意見。

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

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China

Tian-Hao Χie 0000-0003-3993-2190; Qiang Wang 0000-0002-7952-1225; Si-Ning Ha 0000-0002-7737-6175;Shu-Jie Cheng 0000-0002-0966-9718; Zheng Niu 0000-0002-8600-455Χ; Χiang-Χiang Ren 0000-0002-6021-5820; Qian Sun 0000-0002-7671-577Χ; Χiao-Shi Jin 0000-0003-0476-7527.

Ma YJ

病理檢查：選擇80iNIKON正置熒光顯微鏡、LEICA 2145輪轉(zhuǎn)石蠟切片機(jī)、Shandon Pathcentre全封閉脫水機(jī)、LEICAST5030染色封片工作站。

Webster JR

作為農(nóng)墾首家派駐紀(jì)檢機(jī)構(gòu)，紀(jì)檢組積極轉(zhuǎn)換思想，牢記責(zé)任使命，找準(zhǔn)職責(zé)定位，理清工作思路，以嵌入工作開展監(jiān)督執(zhí)紀(jì)，認(rèn)真履行工作職責(zé)。

Ma YJ