대한외과학회지：제 76 권 제 2 호□ 증 례 □

Vol. 76, No. 2, February, 2009

119

Correspondence to: Tae Ui Lee, Department of Surgery, Chungju Hospital, Konkuk University College of Medicine, 620-5, Kyo- Hyun 2-dong Cheongju 380-704, Korea. Tel: 043-840-8240, Fax:043-840-8529, E-mail: tulee@kku.ac.kr

Received April 22, 2008, Accepted September 10, 2008

An Ileocutaneous Fistula That Developed 12 Years after Repair of an Abdominal Wall Defect Using Intraperitoneal Placement of

High-density Polypropylene Mesh (MarlexⓇ)

Departments of Urology and 1Surgery, Chungju Hospital, Konkuk University College of Medicine, Cheongju, Korea

Woo Sung Hong, M.D., Jun Min Lee, M.D., Hong Chung, M.D., Tong-Wook Kim, M.D., Ph.D., Sang-Kuk Yang, M.D., Ph.D., Hong Sup Kim, M.D., Ph.D., Tae Ui Lee, M.D., Ph.D.

1

Although prosthetic materials are commonly used to repair abdominal wall defects, they are also associated with postoperative complications. These complications could be prevented by the adoption of uniform guidelines on surgical methods and materials, but the best anatomical position for placement of prosthetic meshes is unclear. We report a case of an enterocutaneous fistula that developed after an abdominal wall defect was repaired by intraperitoneal application of a prosthetic mesh (MarlexⓇ) to raise awareness of the consequences of improper use of prosthetic materials. (J Korean Surg Soc 2009;76:119-122)

Key Words: Surgical mesh, Intestinal fistula, Abdominal wall, Polypropylene

INTRODUCTION

Although surgical techniques for repairing abdominal

wall defects have improved in recent years, recurrence is

still common. Prosthetic mesh is widely used for repairing

abdominal wall defects, but there are no established

methods or guidelines for reducing postoperative compli-

cations associated with this technique. The efficacy of

intraperitoneal mesh for abdominal wall defects is contro-

versial. Some studies have shown that intraperitoneal

polypropylene mesh with omental coverage is effective and

results in few complications, but others have indicated that

polypropylene meshes are associated with a high incidence

of postoperative complications when they are used within

the peritoneum. Therefore, intraperitoneal placement of

mesh should be avoided whenever possible. In this report,

we describe a case of intestinal fistula that developed after

an abdominal wall defect was repaired by peritoneal

placement of high-density polypropylene mesh (MarlexⓇ).

CASE REPORT

A 57-year-old female patient presented with painful

bleeding and leakage of fecal material from the site of a

previous abdominal incision, which was located to the right

of the umbilicus. She underwent a left hemicolectomy and

a colostomy at a provincial hospital because of colon cancer

15 years previously. She also underwent a subtotal colec-

tomy and an ileostomy because of colon infarction induced

by a mesenteric thromboembolism after a traffic accident

3 years after the first operation. Extensive debridement was

performed because necrotizing fasciitis of the abdominal

wall and evisceration developed 5 days after the operation.

Seven days after the operation, abdominal wall reconstruc-

tion using intraperitoneal placement of high-density poly-

propylene mesh (MarlexⓇ) was performed without placing

tension on the abdominal wall.

Five years after the second operation, the patient

presented at the Department of General Surgery of our

120 J Korean Surg Soc. Vol. 76, No. 2

Fig. 1. (A) Abdominal spiral computed tomography (CT). This study revealed tubular structure, which was suspiciously thought to be partof the bowel, was protruded through the defect on the midline between rectus abdominis muscles. This suspicious bowel and adjacentparietal peritoneum showed diffused wall thickening and prominent enhancement. (B) Enterocutaneous fistulogram with Gastrografinfor the confirmation of fistula between abdominal skin and ileum. Contrast material was identified at small bowel, but there wasno extravasation or collection of contrast material through the fistula tract.

Fig. 2. (A) Intraoperative findings of laparotomy for previously indwelt intraperitoneal pros-thetic mesh removal. (B) Removed polypropylene pros-thetic meshes. These showed grayish, tan, and irregular soft tissue appearances. The larger removed mesh mea-sures 7.8×4.5 cm and the others measure similarly.

hospital complaining of fecal discharge from a wound that

had formed around the umbilicus as a result of the

previous operation. Physical examination revealed that the

fecal material was passing through a fistula which had

developed 3 cm above the umbilicus at the site of previous

midline incision. The patient declined surgical intervention

because of cachexia and the adhesive state of the infected

wound. The enterocutaneous fistula was managed conserva-

tively using periodic dressing and medication. After 7 years

of conservative treatment, the length of the fistula in-

creased to 7 cm and the patient acceded to operative

treatment.

Computed tomography revealed a tubular structure,

which appeared to be a part of the bowel, protruding

through the defect on the midline between the rectus

abdominis muscles. The structure and adjacent parietal

peritoneum exhibited diffuse wall thickening and

prominent enhancement (Fig. 1A). A fistulogram revealed

a long ileocutaneous fistula, which was coincident with the

clinical findings (Fig. 1B).

A 15 cm long midline abdominal incision was made

under general anesthesia. Three pieces of polypropylene

mesh from the previous operation were discovered during

sharp dissection of the mucosa of the fistula. The mesh

Woo Sung Hong, et al：An Ileocutaneous Fistula That Developed 12 Years after Repair of an Abdominal Wall Defect Using Intraperitoneal Placement of High-density Polypropylene Mesh (MarlexⓇ) 121

Fig. 3. Microscopic finding of the removed high-density polypro-pylene mesh. This is a plastic meshwork with foreign bodyreaction that contained inflamed granulation tissue and showed hemorrhagic and necrotizing inflammation (Hema-toxylin-eosin stain, Magnification ×100).

adhered to the tissue and had infiltrated abdominal wall

tissue in the proximity of the tract of the fistula. The pieces

of mesh were removed by sharp dissection. The pieces were

gray to tan in color, and the associated soft tissue had an

irregular appearance. The largest piece was 7.8×4.5 cm (Fig.

2). The mucosa of the fistula tract was dissected away from

the surrounding adherent tissue. The rim of the perforated

layer of mucosa was debrided and closed with a double

layer of tissue. Finally, the abdominal layers were closed

using interrupted one-layer non-absorbable sutures. Two

silastic drains were inserted into the subcutaneous tissue.

Pathological examination showed that the mesh had

induced an immune reaction that resulted in accumulation

of inflamed granular tissue and hemorrhagic, necrotizing

inflammation (Fig. 3). There was no evidence of fecal

material from the wound at the 6-month follow-up visit.

DISCUSSION

The annual number of operations performed in Korea

to repair abdominal wall defects, including hernias, is in

excess of 30,000, which is 70% more than that performed

5 years ago. However, the introduction of tension-free

surgical techniques and prosthetic material has reduced the

incidence of recurrence from 20∼30% to 0∼10%.(1)

Serious complications are mainly associated with the

position of prosthetic meshes relative to the abdominal

wall. Mesh may be positioned in three ways: onlay, sublay

(preperitoneal), and intraperitoneal.(2) The intraperitoneal

position is commonly used in combination with omental

interposition, which is applied to close the peritoneum

without applying tension. Ideally, the prosthesis would

become tightly incorporated into the abdominal wall by

scar tissue formed during the regeneration process. In this

position, the prosthetic mesh is in contact with the bowel,

which may cause dense adhesions, mesh migration, mesh

erosion into adjacent anatomical structures, and enterocuta-

neous fistulas. Such complications may promote infection

and inhibit movement of the abdominal wall.(2,3)

Infection is the most devastating complication associated

with implantation of prosthetic materials.(4) The incidence

of infection after primary abdominal wall reconstruction

with mesh is 1∼2%.(5) LeBlanc(6) concluded that wound

infection is a risk factor for hernia recurrence. Therefore,

nonabsorbable mesh, which is frequently used to repair

large, complex abdominal wall defects, is associated with

an increased risk of wound-related complications. Basoglu

et al.(7) mentioned that contact between mesh and the

bowel should be avoided to prevent complications such as

enterocutaneous fistulas.

Vrijland et al.(8) suggested that intraperitoneal place-

ment of polypropylene mesh is safe provided that surgery

is conducted under antibiotic cover. Bulic et al.(9) reported

that a large, infected abdominal wall defect combined with

evisceration and a colostomy because of a gunshot wound

was successfully treated with polypropylene mesh reinforce-

ment and free latissimus dorsi muscle-flap coverage, and

that the patient’s condition 12 months after surgery was

good.

These inconsistent results and the multiple options

available for managing complex abdominal wall defects may

lead to confusion among surgeons. Grevious et al.(10)

stated that a thorough understanding of the anatomical

structure and function of the abdominal wall is necessary

122 J Korean Surg Soc. Vol. 76, No. 2

to determine the most appropriate technique for a specific

reconstruction. To date, surgery for complex abdominal

wall defects has only been successful when knowledge of

structural anatomy has been integrated with an under-

standing of the abdominal wall function of individual

patients.

We believe that the risk of developing an enterocuta-

neous fistula after intraperitoneal placement of Marlex

mesh outweighs the benefits of this procedure. When there

is direct contact between Marlex mesh and the intestines,

mesh erosion and fistula formation are inevitable. Other

materials, such as polytetrafluoroethylene (Gore-TexTM,

PTFE) mesh, can be substituted for Marlex mesh to prevent

the formation of enterocutaneous fistulas after repairing

large abdominal wall defects.

The purpose of this report is to raise awareness that

prosthetic materials can have adverse consequences. If

treatment options for abdominal wall defects are consi-

dered on a case-by-case basis, the serious postoperative

complications may be prevented.

REFERENCES

1) Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional

hernias. Arch Surg 1998;133:378-82. 2) Halm JA, de Wall LL, Steyerberg EW, Jeekel J, Lange JF.

Intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery. World J Surg 2007;31:423-9.

3) Losanoff JE, Richman BW, Jones JW. Entero-colocutaneous fistula: a late consequence of polypropylene mesh abdominal wall repair: case report and review of the literature. Hernia 2002;6:144-7.

4) Engelsman AF, van der Mei HC, Ploeg RJ, Busscher HJ. The phenomenon of infection with abdominal wall reconstruction. Biomaterials 2007;28:2314-27.

5) Deysine M. Pathophysiology, prevention, and management of prosthetic infections in hernia surgery. Surg Clin North Am 1998;78:1105-15.

6) LeBlanc KA. Laparoscopic incisional and ventral hernia repair: complications-how to avoid and handle. Hernia 2004;8:323-31.

7) Basoglu M, Yildirgan MI, Yilmaz I, Balik A, Celebi F, Atamanalp SS, et al. Late complications of incisional hernias following prosthetic mesh repair. Acta Chir Belg 2004;104: 425-8.

8) Vrijland WW, Jeekel J, Steyerberg EW, Den Hoed PT, Bonjer HJ. Intraperitoneal polypropylene mesh repair of incisional hernia is not associated with enterocutaneous fistula. Br J Surg 2000;87:348-52.

9) Bulic K, Dzepina I, Mijatovic D, Unusic J. Prosthetic mesh for infected abdominal wall defects? Report of a patient with a large full thickness abdominal wall defect and colostomy due to a gunshot wound. J Plast Reconstr Aesthet Surg 2008;61:455-8.

10) Grevious MA, Cohen M, Shah SR, Rodriguez P. Structural and functional anatomy of the abdominal wall. Clin Plast Surg 2006;33:169-79.