The use of mesh plug in hernioplasty was introduced by Shulman et al1 in 1990 as a "rolled plug" fixed with two stitches to close the internal inguinal ring. Robbins and Rutkow2 described their mesh plug technique in 1993. In the following years, this technique and the type and size of plug have been modified deliberately by others. The technique now is commonly used to repair inguinal hernia but complications occur because of migration of mesh plug after open inguinal hernioplasty. We present a case of strangulated bowel obstruction resulting from migration of mesh plug after open inguinal hernioplasty.
An 85-year-old man was admitted to the Emergency Department of our hospital on August 2006, complaining sudden right lower abdominal pain and vomiting for 5 hours, but neither fever nor bloody stool. Physical examination revealed tenderness and rebound tenderness at the right lower abdomen with muscle guarding and a 5-cm surgical scar. He had had a right indirect inguinal hernioplasty with mesh plug 4 years ago in a local hospital. Abdominal X-ray showed a mechanical small bowel obstruction. Abdominal CT demonstrated a strangulated and necrotic bowel obstruction (Figure 1). Emergency laparotomic exploration revealed about 2000 ml of bloody fluid accumulated in the abdominal and pelvic cavities. The plug had migrated away from the internal ring with extensive adhesion between the mesh plug and terminal ileum, which caused an internal hernia.
Approximately one meter of the ileum was incarcerated, black in color and necrotic (Figure 2). The strangulated intestine was resected, followed by an end-to-end ileal anastomosis. The patient recovered uneventfully.
Tension-free hernia repair with polypropylene mesh plug and patch is currently one of the most popular techniques for open inguinal hernioplasty. It is well tolerated by most patients with few complications. A prospective study by Millikan and colleagues3 demonstrated the safety and efficacy of the mesh plug hernioplasty. The mesh plug technique for repair of inguinal hernia has become one of the common procedures in general surgery.
In spite of these excellent results, later complications related to mesh plug still occur. Mehta et al4 reported a case of recurrent hernia resulted from a previously open mesh plug repair. At laparoscopic repair, the patient was found to have considerable adhesions mingled with the plug. Dieter5 described a new, symptomatic scrotal mass that was resected and found to be a mesh plug from previous herniorrhaphy. Nowak et al6 reported a severe complication that may result from inappropriate placement of a mesh plug, i.e. the mesh plug migrated into the patient's scrotum, resulting in a strangulating bowel obstruction. Tokunaga et al7 reported a case of sigmoid colon diverticulosis adherent with migrating mesh plug after repair of open inguinal hernia. Stout et al8 reported a case of small bowel volvulus caused by migrating mesh plug. Our case also illustrates that intra-abdominal adhesion may cause an internal hernia after surgery for open mesh plug hernia. Hence attention should be paid to this severe complication to avoid further morbidity and mortality.
The cause of mesh plug migration may be partially due to poor technical skills. Some authors5,6,9 concluded that the plug had not been anchored in place with suture and suggested that several methods have been proposed such as suturing the plug and patch together or using an all-in-one design such as the Prolene Hernia System. As for the adhesion caused by mesh plug, Mehta et al4 speculated that a small amount of stripping of the peritoneum from the overlying transversalis fascia during placement of the mesh plug resulted in its partial devascularization and subsequent formation of scar tissue and then led to the development of adhesions. According to our experience, it may be related to technical errors, such as wrong placement and inadequate anchorage fixation, improper bigger mesh plug which was settled too deep into the abdominal cavity.
Regardless of the technique used, the potential risk of plug migration should be well understood by the surgeon. This complication should be highly suspicious when evaluating patients who have had inguinal hernia repair and symptoms of acute small bowel obstruction, particularly when there is no previous history of abdominal surgery. Only alertness and energetic evaluation plus immediate therapy can avoid the clinical catastrophe.
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