Synthetic Mesh Defect and Migration Causes Severe Abdominal Infection and Fistula Formation

This case involves a sixty-year-old female patient with a history of Crohn’s disease along with multiple abdominal surgeries. The patient presented to the emergency room with a symptomatic and recurrent ventral hernia. On examination, the physician identified a palpable and reducible hernia that was just above the umbilicus. The examination also revealed a small asymptomatic right inguinal hernia. The patient underwent a mesh repair surgery using Composix Kugel mesh and, during the procedure, the surgeon identified a large defect to the end of the umbilicus with extensive dissection required during the operation. There were also reports of significant scarring from prior repairs but a prolene mesh was utilized and sutured in place behind the rectus muscles. Post-operatively, the patient’s course was uneventful and she was discharged home with a drain in place but without antibiotics. The staples and drain were removed 6 days post surgery and that evening the patient developed a fever and complained of severe abdominal discomfort. The patient presented to the emergency room with complaints of dehydration and worsening abdominal pain. A CT-abdomen was performed that revealed free fluid and air in the subcutaneous space above the hernia repair site and what appeared to be a crumpled mesh device. The patient was taken back to the operating room where it was discovered that the mesh device had separated from the fascia. Pus and purulent material spilled out of the wound upon re-exploration of the site, with cultures revealing positive bacterial growth. A pinhole-sized fistula was also identified which required persistent wound care post-operatively.

Question(s) For Expert Witness

1. Should a mesh-related injury have been suspected sooner given the clinical picture?

Expert Witness Response

Surgeons often perform mesh repair surgery for patients with recurrent hernias. The mesh is often made of polypropylene, a plastic like material that is placed below the skin and over the hernia. This can lower the risk of hernia recurrence. Although there is great benefit to mesh surgery repair, there are risks involved. Polypropolyene meshes have a tendency to erode from days to years. Other complications include fistula formation, migration, infection, and rejection (very rare). These long-term, clinical complications can be serious and patients should always be monitored post-surgery. In this particular case, the patient presents six days status post surgery with complaints of abdominal discomfort. Infection in the abdominal cavity is possible given her fever and abdominal pain. Furthermore, she was not on any antibiotics.