Enterocutaneous Fistula and Abscess Diagnosed with Point-of-care Ultrasound

Case Presentation: A 64-year-old female with history of umbilical hernia repair with mesh 18 years prior, cystocele, and diabetes mellitus presented with 10 days of abdominal and flank pain. The patient was tachycardic, normotensive, afebrile, and had an erythematous, tender, protuberant abdominal wall mass. Point-of-care ultrasound (POCUS) revealed an irregular, heterogeneous extraperitoneal fluid collection with intraperitoneal communication; these findings were consistent with an abscess and infected mesh with evidence for intraperitoneal extension. The diagnosis of enterocutaneous fistula (ECF) with infected mesh and abdominal wall abscess was confirmed with computed tomography and the patient was admitted for antibiotics and source control. Discussion: A rare complication of hernia repair with mesh, ECF typically occurs later than more common complications including cellulitis, hernia recurrence, and bowel obstruction. In the emergency department, POCUS is commonly used to evaluate for abscess; in other settings, comprehensive ultrasound is used to evaluate for complications after hernia repair with mesh. However, to date there is no literature reporting POCUS diagnosis of ECF or mesh infection. This case suggests that distant surgery should not preclude consideration of mesh infection and ECF, and that POCUS may be useful in evaluating for these complications.

Evaluation of the effectiveness of negative pressure wound therapy in the complex treatment of patients with infected mesh endoprostheses of the anterior abdominal wall

Introduction. Wound complications after the placing of various implants of the abdominal wall after hernia repair account for up to 15 % of all hospitalizations with purulent diseases. Their treatment is often accompanied by a high frequency of explantation of a mesh endoprosthesis with a risk of recurrent hernias in this category of patients.The objective of the study was to improve the results of surgical treatment of patients with infected implants of the abdominal wall after herniaplasty based on the assessment of the effectiveness of the negative pressure wound therapy (NPWT).Methods and materials. A retrospective analysis of the treatment results of patients with infected mesh endoprostheses of the anterior abdominal wall (n=68) was carried out. We formed for comparison two homogeneous representative groups of patients, who underwent adequate debridement of a purulent wound with empirical antibiotic therapy. Patients from the study group (n=38) received local therapy using NPWT, patients from the control group (n=30) received traditional local therapy. The evaluation of the treatment results was carried out according to a number of criteria: the course of the systemic inflammatory reaction, the dynamics of reparative processes in the wound of the anterior abdominal wall, evaluation of the clinical outcomes of treatment of patients.Results. The use of vacuum therapy was accompanied by a positive effect on the course of the systemic inflammatory reaction, stimulation of reparative processes in the wound due to the rapid elimination of bacterial agents from the wound cavity (p= 0.003), as well as significant retraction of the wound cavity (p=0.004) compared to traditional methods of wound treatment. Patients from the study group had more favorable treatment outcomes such as a reduction in the duration of hospitalization (p=0.005) and the number of surgical interventions (p=0.003). Due to the NPWT, it was possible to save implants in 30 patients out of 38 (78.9%) with infected mesh endoprostheses of the anterior abdominal wall, which prevented the formation of recurrent hernias and helped to avoid reoperations in this category of patients.Conclusion. The use NPWT is a safe and effective method for treating wounds of the anterior abdominal wall with infected mesh endoprostheses after hernioplasty.

Short-Term Outcomes Following Removal of Infected Hernia Mesh

There are limited studies regarding outcomes of replacing an infected mesh with another mesh. We reviewed short-term outcomes following infected mesh removal and whether placement of new mesh is associated with worse outcomes. Patients who underwent hernia repair with infected mesh removal were identified from 2005 to 2018 American College of Surgeons-National Surgical Quality Improvement Program database. They were divided into new mesh (Mesh+) or no mesh (Mesh-) groups. Bivariate and multivariate logistic regression analyses were used to compare morbidity between the two groups and to identify associated risk factors. Of 1660 patients, 49.3% received new mesh, with higher morbidity in the Mesh+ (35.9% vs. 30.3%; P = .016), but without higher rates of surgical site infection (SSI) (21.3% vs. 19.7%; P = .465). Mesh+ had higher rates of acute kidney injury (1.3% vs. .4%; P = .028), UTI (3.1% vs. 1.3%, P = .014), ventilator dependence (4.9% vs. 2.4%; P = .006), and longer LOS (8.6 vs. 7 days, P < .001). Multivariate logistic regression showed new mesh placement (OR: 1.41; 95% CI: 1.07-1.85; P = .014), body mass index (OR: 1.02; 95% CI: 1.00-1.03; P = .022), and smoking (OR: 1.43; 95% CI: 1.05-1.95; P = .025) as risk factors independently associated with increased morbidity. New mesh placement at time of infected mesh removal is associated with increased morbidity but not with SSI. Body mass index and smoking history continue to contribute to postoperative morbidity during subsequent operations for complications.

Inguinal abscess following Trans-abdominal Preperitoneal Mesh repair for inguinal hernia

Introduction: Laparoscopic hernia surgery is performed by almost every general and laparoscopic surgeon worldwide, Trans-abdominal Preperitoneal (TAPP) and Totally Extraperitoneal (TEP) being the most frequently performed. Seroma formation leading to deep seated mesh infection with abscess is rare but once it occurs it can be very difficult to treat. The rate of mesh infection after open mesh repair is reported to be between 0.5% - 3%, whereas in laparoscopic repair is less than 0.16%. Seroma formation following TAPP is 3%-8% and following TEP is 0.5-12.2%. Case Report: A 19 years old male presented with groin swelling, fever and weight loss three months after the laparoscopic TAPP surgery for right inguinal hernia. Workup showed he had developed mesh infection with pre-peritoneal abscess which was managed with open drainage of the abscess with removal of the infected mesh. Conclusion: Seroma formation may result in abscess formation. If occurred removal of the mesh with drainage of abscess is often required. The chance of recurrence of hernia following management of infected mesh should always be considered