Chronic Ventral Hernioplasty Mesh Infection with Enterocutaneous Fistulae: Operative Treatment of a 62-Year-Old Female with a History of Extensive Abdominal Surgery

Background: Enterocutaneous fistulae (ECF) are abnormal communications between the small or large bowel and the skin. They arise as complications of abdominal surgery, in this case years after intraperitoneal polypropylene mesh placement during ventral hernia repair. Surgical management of infected hernia mesh entails en bloc removal of the infected mesh with the adjacent fistula tract. Case Information: A 62-year-old Hispanic female presented to the general surgery clinic for evaluation of an ECF in the context of chronic ventral hernia mesh infection. The patient had an extensive abdominal surgical history that included two cesarean sections, hysterectomy, three ventral hernia repairs, a sigmoid colectomy, a laparoscopic adjustable gastric band, and a cholecystectomy. The patient noted a fistula formed two years prior and eventually closed spontaneously. 4-5 months prior, the fistula opened again with pain and pasty discharge requiring dressing changes every 2-3 hours. Upon evaluation in the clinic, the patient had infected intraperitoneal mesh with an enterocutaneous fistula. Given the patient's good nutritional status, en bloc excision of the infected mesh and ECF with small bowel resection and abdominal wall closure was planned and performed. During surgery, mesh was identified and noted to be extending across the abdominal wall and the enterocutaneous fistulae were noted. The small and large bowel were densely adhered. Extensive lysis of adhesions using Metzenbaum scissors was performed. Small bowel that was proximally and distally attached to the mesh was identified. The mesh was bisected at midline to facilitate dissection. The infected mesh along with the ECF were removed. Primary hand-sewn side to side anastomosis was performed to repair the defect. The small bowel anastomosis was brought together by approximating the sides. A two-layer anastomosis was created using Lambert and Connell stitches, and the peritoneal cavity was cleaned and closed. The patient was awakened and taken to the PACU in stable condition. The patient's post-op course was complicated by fascial dehiscence requiring multiple laparotomy reopenings, revision of anastomoses due to perforations, further small and large bowel resections due to non-viability, colostomy, mesh placement to cover the open abdominal defect, and several wound VAC replacements. The patient remained stable and continued to receive wound VAC replacements every three days until she was discharged to a skilled nursing facility several months after the hernia mesh was removed. Discussion: Hernia repair mesh that is placed inside the peritoneal cavity has a propensity to cause catastrophic long-term problems such as the ECF presented in this case. Mesh placement between abdominal wall layers, i.e. retrorectus or preperitoneal placement, has been shown to reduce infection and hernia recurrence rates compared to intraperitoneal placement. Patients need to be made aware of the risks of intraperitoneal mesh placement and surgeons need to be encouraged to take the time to prevent these tragic outcomes by improving the hernia repair technique.