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Mind the gap: imaging spectrum of abdominal ventral hernia repair complications
© The Author(s). 2019
- Received: 15 November 2018
- Accepted: 7 March 2019
- Published: 29 March 2019
Ventral hernia repair with or without mesh placement is a commonly done procedure. Laparoscopic approach is more preferred than open in recent surgical practice. Complications occur as like any other abdominal surgeries and are dependent on multiple factors. Complications such as collections, adhesions, and related changes are non-specific. Specific complications related to hernia repair include recurrent hernia, mesh infection, mesh migration, and fistula formation. Post inguinal hernia repair chronic inguinal pain is gaining more attention with increasing use of image-guided nerve interventions for symptomatic management. Imaging plays a vital role in defining and delineating the type and extent of complications. Prior knowledge of the surgical indication and technique helps in better imaging interpretation of complications. This article describes the role of imaging in diagnosis of complications in general ventral hernia surgery setting.
- Computed tomography
- Magnetic resonance imaging
Multiple factors (type of hernia, surgical technique, and patient comorbidities) influence the complication rate and type in post ventral hernia repair.
Multimodality imaging (especially CT) is essential for the adequate diagnosis of various complications that can occur post hernia repair.
Combined surgeon–radiologist participation is imperative in diagnosis and prompt management.
Ventral hernia repair with or without mesh placement is a commonly done procedure either using laparoscopic approach or open techniques with former preferred than latter. Complications occur as like any other abdominal surgeries and are dependent on multiple factors. Complications such as collections, adhesions, and related changes are nonspecific and are common to any abdominal surgery. Specific complications related to hernia repair include recurrent hernia, mesh infection, mesh migration, fistula formation, and infertility. Post inguinal hernia repair chronic inguinal pain is being recognized more frequently with increasing use of image-guided nerve interventions for symptomatic management. Imaging plays a vital role in defining and delineating the type and extent of complications. Prior knowledge of the surgical indication and technique helps in better imaging interpretation of complications.
Complications of hernia repair
Complications of hernia repair
• Adhesions and small bowel obstruction
• Recurrent hernia
• Mesh infection
• Mesh migration
• Fistulization with adjacent viscera
• Post hernia repair chronic pain
Factors influencing complications
Factors influencing complications
• Type and content of hernia
• Surgical technique and mesh selection
- Open vs laparoscopic
- Instrument sterility
- Mesh properties
• Patient factors
Factors influencing complications
Type of hernia: Higher chances of complications are seen with repair of parastomal hernia, recurrent hernia, and hernias with large and multiple defects (Swiss cheese pattern). The contents of the hernia also influence the complication rate with bowel relatively more predisposing than omentum or mesentery . Hernias that require bowel anastomoses are relatively more prone as the surgical times are prolonged and its inherent predisposal due to bowel handling.
Surgical technique and type of mesh: Onlay techniques show a higher complication rate than laparoscopic approach [3, 4]. Use of mesh in hernia repairs has reduced the complication rates compared to direct suturing. Even with mesh usage, inadequate fixation of the mesh, shrinkage of mesh can lead to recurrent hernia. Hence exact pre-operative assessment of the size and multiplicity of the defects is necessary for mesh selection. Mesh is a foreign body and various materials from metallic to biologic have been used. In the present surgical practice, the most commonly used mesh is polypropylene based with modifications in internal make, layering, compositeness, etc. and is quite variable with each center of practice and surgeon selection. The inherent characteristics of the mesh influence the outcome. Mesh material, pore size, weight, and filament type all are shown to alter the outcomes .
Patient factors: Defective or delayed healing and predisposition to infection is seen in patients with smoking, diabetes, obesity, and on steroid intake. In a study by Vidovic et al. , the hernia recurrence rate was 30.3%, with recurrence occurring more with tissue repair than with prosthesis. The authors stated that the recurrence was influenced by type of repair, obesity, hernia size, wound healing disorders, and some chronic comorbidities.
Imaging in complications
Seroma: Seroma cannot be considered as a complication as it is a normal occurrence and is secondary to fluid collection comprising of blood and lymph due to dissection of tissue planes especially in laparoscopic approach. The size of the seroma is proportionate to the amount of dissection. Resolution occurs in 95% cases. Rana et al.  reported seroma incidence of 44% in their study where hernioplasty with onlay technique was used. Seroma is complicated if it persists more than 6 weeks, is symptomatic, or increasing in size . It is important to distinguish between seroma and an infected collection as the latter requires drainage and specific antibiotic therapy. Imaging depicts seroma as a well/ill-defined collection within the dead space. Wall is thin or imperceptible with no or minimal enhancement. Usually, the collection is anterior to the mesh. Fat lobules can be seen within the seroma (Fig. 5). Infected seromas show thick, vascularized wall with exudative content and may be accompanied by signs and symptoms of inflammation. A diagnostic aspiration is helpful to identify the organism and provide antibiotic sensitivity profile.
Hematoma: Hematomas usually resolve and are dependent on surgical technique. They are seen as ill-defined heteroechoic collections on USG or hyperdense on plain CT (Fig. 6). Rarely, they expand if there is active ooze which can be picked on contrast CT. Spermatic cord hematomas are common with inguinal hernia repairs and usually resolve .
Adhesions: Adhesions can occur with any intraabdominal surgery and are the most common cause of small bowel obstruction in a postoperative abdomen. Use of composite mesh has shown to reduce the adhesions as well aiding in better meshoma formation . On imaging, clues to adhesion-related obstruction include clumping of loops, adhesion of bowel to anterior abdominal wall, visualization of fat containing band, and acute angulation of loops at the site of transition (Fig. 7).
Infection: Incidence of infection in post hernia repair is highly variable (0–36%) and is dependent on many factors. Common causative organisms include Staphylococcus (esp Methicillin resistant), Streptococcus, Escherichia coli, and anaerobic bacteria. Unique organism associated with implant infection include nontuberculous Mycobacterium which is seen in developing countries. Repair of complex hernias, hernias containing bowel and requiring bowel anastomosis, parastomal hernias, longer surgical time, equipment sterility, and impeded patient immune response have higher risk of infection. Microporous and multifilament mesh have higher predisposal to infection . Mesh infection is generally managed by systemic antibiotics, drainage in case of abscess, and removal of mesh if deep infection is suspected. Removal of mesh is followed by resuturing/placement of biodegradable mesh which incite less tissue reaction. Infection can predispose to sinus formation, mesh migration, and erosion into viscera. Imaging helps in delineating the extent of infection and associated visceral involvement (Figs. 8 and 9).
Nontubercular Mycobacterium are resistant rapidly growing mycobacterium including common species such as Mycobacterium chelonae, Mycobacterium goodie, Mycobacterium fortuitum, and Mycobacterium abscesses. They have predilection for implants and are reported with hernia mesh, breast implants, and orthopedic prosthesis. Contamination occurs through inadequate high grade sterilization of instruments, rinsing with tap water and using partially dried instruments. These organisms have affinity for dermis and subcutaneous tissue and typically present at 3–4 weeks’ post-surgery appearing as an erythematous nodule followed by sinus formation .
Recurrent hernia: Usually occurs within 2–3 years of surgery with an incidence ranging 0.3–10%. The frequency depends on surgical technique, obesity, post op complications, and relatively more with use of mesh with less tensile strength and mechanical stability . Recurrence is common with repairs without mesh and open methods. Hernia recurrence invariably occurs at the margin of the mesh if used—at the “mesh—tissue” interface  (Fig. 10). Clinical diagnosis may be limited by overlying fibrosis and imaging is required in such cases. On sonography, the mesh margins should be evaluated utilizing Valsalva technique and without too much probe pressure to rule out reducible hernias.
Mesh migration: The exact incidence of mesh migration is unknown as reports are usually based on single case complications [17–21]. It generally occurs years later. The probable causes of mesh migration are divided into primary and secondary . Primary is a mechanical migration where an inadequately secured mesh moves along planes of least resistance and secondary is through transanatomical planes as a result of inflammation, infection, and foreign body reaction. Mesh migration to urinary bladder, bowel, and scrotum has been reported with inguinal hernia and incisional hernia repairs. Migration into bowel can cause complications such as infection, obstruction, or fistula formation (Fig. 11). Collapsed mesh is best seen on USG as crumpled echogenic structure at an unexpected site or within a collection (Fig. 12). Tackers which are radiodense can aid in mesh localization on CT. Mesh migration, adhesion, and focal thickening of visceral wall suggest underlying erosion. Imaging is vital for management in providing details about viscera involved, extent of involvement and whether the migrated mesh can be removed endoscopically or require open removal.
Fistulization with adjacent viscera: It is a rare complication and is secondary to migration of mesh and erosion of adjacent viscera or due to deep infection resulting in extension to nearby organs or secondary to inadvertent inclusion of bowel/bladder in the sutures. Fistulization with small bowel, sigmoid colon, and urinary bladder has been reported in literature [18, 20, 21, 23] with both polypropelene and composite dual mesh (Figs. 13 and 14). Combined multimodality imaging approach (USG, CT) is preferred for diagnosis. Endoscopy can be used for diagnosis and retrieval of mesh in cases with colon involvement. CT protocol has to be modified according to clinical suspicion and use of positive contrast as in cystogram/oral route helps in fistula characterization (Fig. 15).
Direct organ injury: urinary bladder injuries are reported with laparoscopic inguinal repairs . Bowel perforation is very rare and can lead to fistula, sepsis, and has increased mortality.
Infertility: injury to the vas deferens and testis at the time of surgery is ~ 0.3% for adults, 0.8–2.0% for children, and 0.5% of primary hernia repairs respectively . Recurrent hernia repairs have higher rates of infertility. These are long-term complication and imaging is not used for diagnosis.
Imaging provides a roadmap of the type and extent of complication. It is imperative that radiologists have prior knowledge about the indication and type of surgical procedure and also decide on the adequate modality choice to provide a fruitful report that aids in management of the complication.
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- Aguirre DA, Santosa AC, Casola G, Sirlin CB (2005) Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi–detector row CT. Radiographics 25(6):1501–1520View ArticleGoogle Scholar
- Rana KV, Singh G, Deshpande NA, Bharathan VK, Sridharan S (2013) Postoperative complications of mesh hernioplasty for incisional hernia repair and factors affecting the occurrence of complications. Med J DY Patil Univ 6:25–31View ArticleGoogle Scholar
- Al Chalabi H, Larkin J, Mehigan B, McCormick P (2015) A systematic review of laparoscopic versus open abdominal incisional hernia repair, with meta-analysis of randomized controlled trials. Int J Surg 20:65–74View ArticleGoogle Scholar
- Tsuruta A, Hirai T, Nakamura M (2014 Aug) Retrospective comparison of open versus laparoscopic ventral and incisional hernia repair. Asian J Endosc Surg 7(3):246–250View ArticleGoogle Scholar
- Brown C, Finch J (2010) Which mesh for hernia repair? Ann R Coll Surg Engl 92(4):272–278. https://doi.org/10.1308/003588410X12664192076296 View ArticlePubMedPubMed CentralGoogle Scholar
- Vidović D, Jurisić D, Franjić BD, Glavan E, Ledinsky M, Bekavac-Beslin M (2006) Factors affecting recurrence after incisional hernia repair. Hernia 10(4):322–325View ArticleGoogle Scholar
- Tonolini M (2016) Multidetector CT of expected findings and complications after contemporary inguinal hernia repair surgery. Diagn Interv Radiol 22(5):422–429View ArticleGoogle Scholar
- Rakic S, LeBlanc KA (2013) The radiologic appearance of prosthetic materials used in hernia repair and a recommended classification. AJR Am J Roentgenol 201:1180–1183View ArticleGoogle Scholar
- Grossi JVM, Manna BB, Montes JHM et al (2014) Analysis with ultrasound of different surgical meshes for abdominal hernia repair: experimental study. Anat Physiol 4:148. https://doi.org/10.4172/2161-0940.1000148 View ArticleGoogle Scholar
- Jamadar DA, Jacobson JA, Girish G et al (2008) Abdominal wall hernia mesh repair—sonography of mesh and common complications. J Ultrasound Med 27:907–917Google Scholar
- Park A, Birch DW, Lovrics P (1998) Laparoscopic and open incisional hernia repair: a comparison study. Surgery 124:816–822View ArticleGoogle Scholar
- Tonolini M, Ippolito S (2016) Multidetector CT of expected findings and early postoperative complications after current techniques for ventral hernia repair. Insights Imaging 7(4):541–551View ArticleGoogle Scholar
- Choudhury DK, Prakash R (2016) Atypical mycobacterial infection following laparoscopic inguinal hernia repair: experience in five cases. IOSR J Dental Med Sci 15(2 Ver XI):40–42Google Scholar
- Vijayaraghavan R, Chandrashekhar R, Sujatha Y, Belagavi CS (2006) Hospital outbreak of atypical mycobacterial infection of port sites after laparoscopic surgery. J Hosp Infect 64:344–347View ArticleGoogle Scholar
- Sohail MR, Smilack JD (2004) Hernia repair mesh-associated Mycobacterium goodii infection. J Clin Microbiol 42(6):2858–2860View ArticleGoogle Scholar
- Bendavid R (1998) Complications of groin hernia surgery. Surg Clin North Am 78:1089–1103View ArticleGoogle Scholar
- Al-Subaie S, Al-Haddad M, Al-Yaqout W, Al-Hajeri M, Claus C (2015) A case of a colocutaneous fistula: a rare complication of mesh migration into the sigmoid colon after open tension-free hernia repair. Int J Surg Case Rep 14:26–29. https://doi.org/10.1016/j.ijscr.2015.06.039 View ArticlePubMedPubMed CentralGoogle Scholar
- Bostanci O, Idiz UO, Yazar M, Mihmanli M (2015) A rare complication of composite dual mesh: migration and Enterocutaneous fistula formation. Case Rep Surg 2015:293659. https://doi.org/10.1155/2015/293659 View ArticlePubMedPubMed CentralGoogle Scholar
- Riaz AA, Ismail M, Barsam A, Bunce CJ (2003) Mesh erosion into the bladder: a late complication of incisional hernia repair. A case report and review of the literature. Hernia 8:158–159Google Scholar
- Nelson EC, Vidovszky TJ (2011) Composite mesh migration into the sigmoid colon following ventral hernia repair. Hernia 15(1):101–103View ArticleGoogle Scholar
- Millas SG, Mesar T, Patel RJ (2015) Chronic abdominal pain after ventral hernia due to mesh migration and erosion into the sigmoid colon from a distant site: a case report and review of literature. Hernia 19(5):849–852View ArticleGoogle Scholar
- Agrawal A, Avill R (2006) Mesh migration following repair of inguinal hernia: a case report and review of literature. Hernia. 10(1):79–82View ArticleGoogle Scholar
- Gandhi D, Marcin S, Xin Z, Asha B, Kaswala D, Zamir B (2011) Chronic abdominal pain secondary to mesh erosion into cecum following incisional hernia repair: a case report and literature review. Ann Gastroenterol 24(4):321–324PubMedPubMed CentralGoogle Scholar
- Sheynkin YR, Hendin BN, Schlegel PN, Goldstein M (1998) Microsurgical repair of iatrogenic injury to the vas deferens. J Urol 159:139–141View ArticleGoogle Scholar
- Bjurstrom MF, Nicol AL, Amid PK, Chen DC (2014) Pain control following inguinal herniorrhaphy: current perspectives. J Pain Res 7:277–290PubMedPubMed CentralGoogle Scholar
- Thomassen I, van Suijlekom JA, van de Gaag A, Ponten JE, Nienhuijs SW (2013) Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks for chronic pain after inguinal hernia repair. Hernia 17:329–332View ArticleGoogle Scholar