Open Mesh Repair Of Different Hernia. Is The Technique Free Of Complications?

Arshad M Malik, Asad Khan, K Altaf Hussain Talpur and Abdul Aziz Laghari

INTRODUCTION:

Implantation of prosthetic mesh in repair of different hernias has gained a global acceptance and popularity. It is thought to be a potent safeguard against recurrence of hernias ^{1, 2}.The use of prosthetic mesh in different types of hernias has brought a phenomenal change in the out look of hernia patients all over the world ³. Today, an ever increasing number of hernias are repaired by implanting prosthetic meshes either by conventional open method or by laparoscopic approach ⁴. Beside its well known advantages and global acceptance in every day hernia surgery, a number of complications are thought to be associated with the use of mesh in different types of hernias ^5-15. We present our experience of mesh related complications in different open hernia repairs and their management in this study. MARERIALS AND METHODS It’s a descriptive observational study over 5 years during which a total number of 1008 patients with different types of hernias were repaired electively    in a teaching hospital as well as in private hospitals by the same surgical team. Of these, 638 (63.29 %) hernias were repaired by implanting prolene mesh of different sizes depending on the size of the defect. A drain was left in place in selected cases .The patients were followed up to a period of three years after discharge from the hospital. The follow up visits were scheduled at 1 month, 6 months, and then yearly. Of the total patients , 432(67.71%) were followed up to three years while 159 (26%) patients were lost in the follow up from day of discharge from the hospital. Another 47 patients attended follow up up to 2 years only and then disappeared. Sixteen of these patients continued to complain about chronic pain and foreign body sensation up to two years and then they did not return while 4 of these patients developed recurrent hernia in one year time but they were lost in follow up. The data of every patient is recorded on a proforma and their follow up records are maintained. The variables studied included immediate, early and late post-operative complications in addition to the demographic details. The statistical analysis of the data is done on SPSS version 12. RESULTS The mean age of the patients is 41 years with a range of 73 years and a STD of 19.089. There is a male dominance (N=531, 83%) over females (N=107, 17 %). The commonest type of hernia in this series is inguinal hernia (n=518, 81%) followed by Para-umbilical hernia (n=83, 13 %). Distribution of different varieties of hernias among male and female study population is shown inTable-I. Table-1. Frequency of hernias and distribution among males and females 

  Of the total number, 34 (5 %) hernias were recurrent hernias including 21 inguinal hernias, 11 Para-umbilical hernias and 2 Incisional hernias. The patients were operated after preliminary investigations and medical fitness. All the patients were operated by open conventional technique regardless of the type of hernia. Total duration of operation is shown in Figure -I with maximum patients (467, 73%) operated with in 60 minutes.  Figure-I.   Total duration of operation: Various early complications during the same admission occurred in 9 % (n=55) of the patients. Their distribution according to the type of hernia is displayed inTable- II. Table-II   Type of hernia * Complications during same hospitalization Cross tabulation 

 Wound infection has an alarmingly high incidence in our series (n=19, 3 %). Most of these infections are superficial and effectively controlled by intensive antibiotic therapy so that the failure of repair is saved and mesh rejection prevented effectively. Four of recurrences occurred during 2 years follow up but patient discontinued follow up afterwards. Remaining 07 recurrences occurred between 24 to 36 weeks. The complications observed during the follow up period of up to three years in different hernias are shown in Table-III.  Table-III    Type of hernia * Late Complications after discharge Cross tabulation 

 A remarkably low incidence of wound infection in para-umbilical and incisional hernia is attributable to the placement of suction drain which prevents hematoma formation and secondary infection. Seven (2%) recurrences occurred in para-umbilical hernias where suction drain did not work. Mesh infection with massive reaction , although, treated conservatively in 5 patients with vigorous antibiotic therapy led to the formation of a weaker scar which later on gave way and recurrence of hernia occurred. Follow up was not 100% and about 26% patients were lost in the follow up. Majority of the patients (n=457, 90 %) were discharged within 4 days while patients who were complicated had a longer stay up to 15 days (P <0.001). Late complications were mostly chronic pain and foreign body sensations with 2 cases of unilateral testicular atrophy. DISCUSSION A number of non-infectious and infectious complications are attributed to the use of mesh in the repair of most of the hernias^{5, 13, 16}. The type of mesh as well as their composition seems to affect complications following their use and specific materials are related to specific complications. We present 638 patients of different types of hernias repaired by implanting polypropylene mesh of varying sizes depending upon the size of defect. Prolene meshes are monofilaments, non-absorbable, inert, sterile and porous synthetic materials commonly used for this purpose. The use of mesh in hernia repair has brought a phenomenal change in the overall outcome of hernia repair especially in terms of recurrence of hernia ¹⁷. We experienced wound infection as the commonest complication in our series (n=19, 3%) and this was more so in the inguinal hernias. Most of the wound infections are superficial and very easy to control on conservative measures. On the contrary deep seated mesh infections are always dreaded complications and if not treated vigorously can lead to total failure and rejection of prosthetic mesh. A number of similar studies have reported an increased infection rate in mesh hernia repair testifying our results ^18-28. Grant AM ²⁹, however claims no difference in the incidence of infection between mesh and non-mesh repair of groin hernias. A severe local reaction occurred in 4 (0.62%) patients which resolved in few days without any consequences. Seroma and hematoma occurred in 11(2 %) and 7(1.09%) patients respectively. Only 3 seromas and one hematoma needed evacuation. We report a recurrence of 11(2 %) hernias of which 4 are inguinal and 7 are para-umbilical hernias. All of the recurrent para-umbilical hernias had severe reaction and wound infection in the post-operative period which was effectively controlled by vigorous antibiotic therapy and local wound care. There is probably a weaker scar after resolution of the infective process which resulted in recurrence. A significantly low recurrence rate in inguinal hernias in our study (0.77%) is consistent with the results of other similar reports ^30-32. Chronic pain and a foreign body sensation poses a real problem and though it occurred in only two cases but a similar study by Bay-Nielsen M ³³ claims 22.9% study population having chronic pain and more so in the adult males. CONCLUSION Although mesh repair is an efficient method of hernia repair, a number of complications may be associated and can lead to failure. An aggressive antibiotic therapy and wound care may control even massive infections.

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