image

Welcome to the International issue of The Surgeons’ Lounge. In this issue, we welcome our readers to respond to the case presented, and be featured as our next “guest expert”! Send your replies to me at szomsts@ccf.org before Sept. 15, 2014. Please do not forget to include your full name and affiliations to ensure you are listed correctly.

Check out the special “Double Express” and see how the experts answer the following questions: “What is the smallest incisional hernia you will not perform laparoscopically?” and “Do you leave any drains after large open- incisional hernia repair with prosthetic mesh?”

Feedback from our readers is our greatest asset. Tell us how we’re doing! What do you want to see more of? Less of? What is the best part of Surgeons’ Lounge? What can we do even better? We look forward to your feedback!

Sincerely,

img-button

Samuel Szomstein, MD, FACS
Editor, The Surgeons’ Lounge
Szomsts@ccf.org


Dr. Szomstein is associate director, Bariatric Institute, Section of Minimally Invasive Surgery, Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston.

Question for Our Readers

Amir Mehran, MD
University Bariatrics, Thousand Oaks, Calif., and
Ara Keshishian, MD,
Central Valley Bariatrics, Verdugo Hills, Calif.

A65-year-old man presented with a painful enlarging symptomatic umbilical hernia that he had for several years. He denied any obstructive gastrointestinal (GI) symptoms or coughing, urinary hesitancy or constipation. His past history was significant for obesity, hypertension, sleep apnea, gastroesophageal reflux disease, mild lower extremity edema and an open appendectomy. He did not use tobacco and took Olmesartan and close to a dozen herbal and naturopathic supplements. Physical examination revealed a body mass index of 34 kg/m2, and a partially reducible umbilical hernia measuring roughly 5 cm in diameter. Mild skin “stretch” discoloration was also noted without any obvious cellulitis.

After a thorough discussion of his options, a decision was made to proceed with a laparoscopic repair with mesh due to his obesity and to avoid going through the discolored area. After a thorough medical evaluation, he underwent an uneventful laparoscopic umbilical hernia repair with a 15 x 20 cm Physiomesh (Ethicon EndoSurgery). The patient had received a 900-mg IV preoperative dose of clindamycin (anaphylactic penicillin allergy) and the mesh had been soaked in antibiotic-laced saline solution.

Two 5-mm ports and a 12-mm port, all nonbladed, were placed along the left abdomen. The hernia contained omentum, which was dissected off using gentle traction and the Harmonic Scalpel (Ethicon EndoSurgery). Using the Securestrap fixation device (Ethicon EndoSurgery), the umbilicus was everted by tacking the hernia sac inside the abdomen, thus giving the patient a normal looking umbilicus (“innie”). The mesh was inserted through the 12-mm port and did not come into contact with the skin at any point. It was secured with four preplaced Gore CV-0 transabdominal fixation sutures (WL Gore), as well as two rows of Securestrap tackers. Diagnostic laparoscopy at the end of the case did not reveal any intraabdominal injuries or bleeding. The Foley catheter, placed at the beginning of the case, was removed without sequelae. The patient tolerated the procedure well and was discharged the same day at his request, once he was able to tolerate fluids and void on his own. He was not discharged on any antibiotics.

The patient did well for the next two weeks but then called about a low-grade fever (100.1 F) associated with coughing, hoarseness and left lower abdominal pain near the left iliac crest. He denied any GI symptoms, pain or redness around the incisions. Due to the driving distance involved, he opted to see his primary care physician (PCP) first. His PCP performed routine laboratory tests and diagnosed him with an upper respiratory infection and possible laryngitis.

The patient was seen in the surgical clinic five days later and was noted to have painless erythema around the umbilicus (Figure 1). His abdominal exam was otherwise unremarkable, including recurrence or seroma formation. On further questioning, however, the patient did complain of a new onset of urinary hesitancy and tenesmus.

image
Figure 1. Day of reoperative surgery.

Because he had never undergone a colonoscopy or annual urologic exam, a rectal examination was performed revealing a large hard prostate and extreme discomfort. The erythema boundaries were marked and the patient was discharged on oral clindamycin. The patient’s PCP subsequently changed the antibiotics to nitrofurantoin because the lab work from five days before showed an Escherichia coli urinary tract infection with elevated serum white blood cell (WBC) count. Of note, the patient’s preoperative WBC was normal and a urinalysis was not performed because he was asymptomatic.

When the patient was contacted a few days later, he reported worsening fever, lethargy and no change in the abdominal wall erythema. He was advised to present to the emergency room where the examination revealed a temperature of 101.9 F, a pulse of 123 beats per minute, persistent periumbilical erythema with warmth, but no abdominal distention or any tenderness to palpation. Laboratory work was significant for a WBC count of 24,000 with left shift and a urinalysis with positive leukocyte esterase, significant pyuria and moderate bacteria. A contrast abdominal computed tomography was performed, demonstrating a prominent prostate, bladder wall thickening and some nonspecific fluid around the mesh and hernia site. The patient was admitted to the hospital and upon consultation with infectious disease consultants, was placed on vancomycin, levofloxacin and metronidazole. The patient did not clinically improve over the next 24 hours and the erythema appeared to have worsened. He was taken to the operating room for a laparoscopic exploration and possible mesh removal. Intraoperatively, the superior aspect of the mesh was found to be clean with minor omental adhesions. The inferior aspect, however, had thicker adhesions with a pocket of fibrinous fluid (Figure 2). Using the Harmonic Scalpel, the mesh was fully excised and removed with an endobag. Gram stain of the mesh revealed no organisms with rare PMNs [polymorphonuclear leukocytes].

image
Figure 2. Intraoperative picture of inferior aspect of mesh.

The patient made a very rapid recovery and was discharged from the hospital within 48 hours on oral antibiotics pending outpatient evaluation and final mesh culture results, which remained negative. Final pathologic examination of the specimen showed adherent fibro adipose tissue with fibrosis, fibrin deposition, foreign body reaction and mostly chronic inflammation. In follow-up visits, the patient remains well and does not wish any further herniorrhaphy.

Questions:

  • Is this case consistent with mesh allergy or mesh infection and what are alternative management options?
  • If this was an allergic reaction, is this the typical course and is this particular mesh (or any other mesh) known for this type of reaction? Is there any rationale for prescribing corticosteroids before reoperative surgery?
  • If this was due to a urinary tract infection, is it likely from a Foley or from prostatitis or both, and is this the course normal (i.e., two weeks postoperatively? No pain and no microbes on path or cultures?)?
  • Should the urinalysis be checked on all patients including asymptomatic men and is there a role for continued antibiotics (IV or oral) after surgery?

Double Expert Express

image

Q.What is the smallest incisional hernia you will not perform laparoscopically?

img-button

David Edelman, MD:
2 cm, but it’s not the size, it’s the symptoms and whether it’s recurrent.

img-button

Ronald A. Hinder, MD:
3 cm

img-button

Nataniel Soper, MD:
3 cm

img-button

Maher Abbas, MD:
2 cm, 3 cm or greater, consider laparoscopy, because sometimes smaller defects can be seen around the hernia site.

img-button

Edward Felix, MD:
Small umbilical or tiny midline congenital hernias. Incisional usually laparoscopic.

img-button

Michael Sarr, MD:
3 cm

img-button

Edward Lin, MD:
3 cm

img-button

Edward H. Phillips, MD:
I prefer open-incisional hernia repair except subxyphoid hernias. Usually the whole wound will eventually deteriorate and recurrences are at the edge of limited repairs. So size doesn’t matter, but for sure any ventral incisional hernia I can repair under local monitored anesthesia care, I will do “open.”

img-button

Dan Herron, MD:
2 cm

img-button

Natan Zundel, MD:
3 cm


Q. Do you leave any drains after large open-incisional hernia repair with prosthetic mesh?

Yes

Edward H. Phillips, MD

Raul Rosenthal, MD

Michael Sarr, MD

Edward Felix, MD

Nataniel Soper, MD

David Edelman, MD

No

Natan Zundel, MD

Edward Lin, MD

Daniel M. Herron, MD

Maher Abbas, MD

Ronald A. Hinder, MD