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Incisional hernia mesh removal
Hello, I am sorry if this is going to be a rather long post, I apologize in advance for it and thank anyone who has the patience to read it.
Six years ago, I had an open abdominoplasty with concurrent prosthetic repair of an incisional hernia that extended from the pubic bone to the xiphoid.
A heavyweight 30×30 cm. polypropylene mesh (J&J Prolene) was used, implanted with the sublay technique, in the retrorectus preperitoneal position.
The entire mesh sheet was cut before use; realistically a piece of 30 cm height and 10-15 width has been implanted.
After 12 days from surgery, I started having sub-occlusive crisis: an intense diffused abdominal pain started about 2 hours after a meal continuing for 4-5 hours until I vomited and that relieved the pain.
I dealt with these crises, occurring approximatively each week, by switching to a liquid diet and maintaining it until I was able to pass gas normally, typically a day or so.
After 3 months from mesh implantation I also started to experience symptoms I never had before like extreme fatigue that forced me to reduce the hours I worked, joint pain especially in the lower back area and in the back of the neck, mind fog, dizziness, memory problems and difficulties walking steady and coordinating movements.
These symptoms never went away, they costed me my job and I still have to cope with them.
After 3 years, one evening the post dinner pain did not go away after vomiting and the next morning I was in the ER.
Radiological finding showed what appeared to be like a bezoar or faecaloma of 6 cm length in my bowel.
A laparoscopy done two months later found no bezoar or faecaloma but intussusception of a small bowel loop caused by adhesions so a partial adhesiolysis was performed freeing the affected segment.
A mesenteric hematoma emerged days from the surgery. It was partially reabsorbed but after one year, a second laparoscopy with partial adhesiolysis was needed for its evacuation through a transverse incision.
After this surgery bowel functionality, which was never optimal to start with, started to deteriorate and radiological exams supported an evidence of partial SBO.
The same surgeon performed another laparoscopic adhesiolysis. This time he said he cut off most of the adhesions and encouraged me to return to a normal fibre-rich diet.
I did it coupled with physical workout and rapidly gained weight and muscular mass.
I reported, however, since 3 days after the surgery a sharp pain in the lower left abdominal quadrant that was associated with gas passage and went away after that happened.
In addition, I lost the defecation reflex. By taking laxatives, I was able to go to the bathroom but even loose stool did not cause the stimulus to evacuate.
After each bowel movement, I also had a diffused burning lasting for hours like if my intestine were severely inflamed.
For three months however, I had a very small improvement of the symptoms that started after mesh implantation (mind fog, fatigue, joint pain etc.) but they were back to their original level after one year when I also started to experience multiple wake ups at night and was unable to sleep for more than four continuous hours.
A barium follow through first and then a CAT scan showed the entire bowel was covered by adhesions as indicated by multiple dilated bowel loops and air-fluid levels and my surgeon proposed another laparoscopic adhesiolysis.
This time he consented to my request of using an adhesion barrier in the surgery.
I had this last surgery four months ago, it lasted just 30 minutes and it was mostly a diagnostic laparoscopy with a very limited adhesiolysis of some ileum loops from the abdominal wall.
Severe adhesions covering my ileus and colon were left untouched maybe because the constant inflammation caused by the mesh would lead to their immediate reformation.
Due to the lack of complete adhesiolysis the adhesion barrier was not used.
The surgeon also reported mild intestinal fibrosis.
Biopsies of found whitish peritoneal lesions and abdominal fluid were also taken showing respectively fibro-adipose tissue and inflammatory cytological report.
Now 4 months have passed from the last surgery, symptomatology is unchanged and bowel functionality is slowly worsening with time. My gastroenterologist thinks I have a systemic autoimmune and auto inflammatory reaction (ASIA) to the mesh implant.
I am waiting for the results of the first immunological tests but at this point, I am wondering if the adhesions and the mesh can be safely removed without also removing the rectus muscles and if after this a primary closure of the abdomen can still be achieved without implanting another mesh.
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8 Replies
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Many thanks for your interest.
Since the first laparoscopy after the abdominoplasty and mesh implantation, I asked the surgeon if he found the mesh to be in direct contact with the bowel.
He said that there was no direct contact as the mesh has been implanted in the preperitoneal position, accordingly to the abdominoplasty surgeon report, and he was only able to “catch a glimpse” of the mesh during the surgery.
He never said anything about the integrity of the fascia repair.
Regarding cutting through the mesh, the surgeon who performed all the surgeries after mesh implantation said he was careful not to cut through the mesh because there would be a very high probability that the mesh would become infected otherwise.
Even when the mesenteric hematoma was evacuated, he said that the transverse incision was made to the side stopping at the mesh border.
Personally, after that surgery I can feel a little roughness of the skin on a zone of about 6 cm of diameter on the side where the transverse incision is.
On the same zone the skin is also a little darker, not by much but definitively appreciable.
It is the same zone where a tissue biopsy showing fibro-adipose tissue has been taken during the last surgery when severe adhesions were found but not lysed.
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I’m curious: you never mentioned if the mesh was exposed and contributed to the adhesions after the abdominoplasty. Did the surgeon mention if your fascia repair was intact when he went in?
also, did they cut through your mesh for the laparoscopic exploration? What about for the transverse incision?It doesnt make sense that you had adhesions after a retrorectus mesh repair.
Also, I ask because vomiting can tear the fascia repair and expose the mesh.
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quote M.G.:I was told that in my case the only solution to remove the mesh was removing the abdominal muscles with it,
This does not seem technically correct. It might be that removing the mesh would be very tedious and time consuming and they don’t want to put in the time and effort, or don’t feel confident in their ability. The tissue that grows in to the mesh is not muscle tissue and it should be possible to separate it from the muscle tissue, leaving functional muscle behind. Whoever said this might really mean that they would take the short path to removing the mesh, leaving you with further damage. The job is too difficult for them.
I think that you need to find the right surgeon, who will take the time to get the mesh out with the least damage.
I am not an expert in anatomy or physiology though. Maybe others can offer better thoughts.
[USER=”2580″]DrBrown[/USER] [USER=”2019″]drkang[/USER] [USER=”935″]drtowfigh[/USER]
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Many thanks for your advice.
I do not expect, after mesh removal, to return like if I had not had any surgery but at least not much worse that the condition I was before the mesh was implanted.
I expect at least the systemic symptoms to disappear almost completely and to be free from the mind fog.
I am also prepared to accept that due to the severe adhesions, intestinal resection may be needed but I hope not to the point where I would have to depend on TPN first and end up with intestinal transplantation later.
It is great to learn that mesh replacement, even with the absorbable biologic mesh, can be avoided and the abdomen can still be properly closed with autologous tissues.
I was told that in my case the only solution to remove the mesh was removing the abdominal muscles with it, and then using an absorbable intraperitoneal mesh that, given the strong foreign body reaction to polypropylene I had, would only lead to even more severe adhesions.
As you may have found from my English I do not live in the U.S. but in the E.U., though I am willing to travel to the U.S. and pay all I can for mesh removal if my current condition can be improved.
A first problem in having the consultation you suggested is that my surgical reports are not in English but I could always translate them as I mostly did in these posts.
Fortunately, my gastroenterologist, who is a university teacher and director of a gastroenterology unit at a large hospital in my country, is willing to help with the consultations.
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I rx a consult with at least 3 top hernia mesh removal specialists. Ignore local surgeons.
Igor Belyanksk in Annapolis MD, and Sherwon Towfigh are definitely two with consulting .
and there are others mentioned in this site that can be the third.
For dr. Towfigh you can pay for a online consult if you can’t travel and Belyanksk will review your case for free-send all copy of scans and op reports and write up a letter explains your history and questions.
Mesh can I’m many cases be removed safely and structures repaired naturally but you have to goto the best of the best.
Be willing to travel and pay out of pocket for this speciality care. Go in with realistic expectations-you may not ever be 100% again but their is hope you can have a higher quality of life than currently. -
Seems like it could for sure be the mesh then if you weren’t having these problems before implantation, especially the systemic symptoms. If I were you I would go with removal.
Any surgery could be high-risk but removal can be done as you can see it has been done to many other members on the forum. In experienced hands it sure is feasible and doable. Removing mesh if it was for an incisional hernia isn’t AS hard as compared to the stories you hear when it comes removing mesh from an inguinal hernia as there are so many structures nearby.
Only downside is that removal of mesh done by experienced and expert hands will most likely involve traveling and possibly paying out of pocket, but there are a good amount of talented surgeons that you can go to no matter what part of the U.S. you are in.
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Hello, thanks for your help, I am 49 and had my first laparotomy at 22 for biliary sepsis from bile duct stones. Adhesions surely formed and their management required subsequent multiple adhesiolysis.
However, before the mesh was implanted, adhesions were not so severe to the point of complete impairment of bowel functionality.
Last adhesiolysis was 5 years before mesh implant.
In those years, I had a perfectly normal quality of life save for occasional episodes of pain that were manageable with NSAID use.
The surgeon who performed the mesh implant reported an easy placement of the mesh with only mild adhesions between viscera and abdominal wall.
Never, before mesh implantation, have inflamed peritoneal fluid and peritoneal lesions or intestinal fibrosis been found.
It is like if the foreign body reaction to the mesh implant caused for me not a local but a systemic inflammatory reaction that in turn led to excessive adhesion (re)formation after surgery.
Regarding systemic symptomatology, I never had any before mesh implant.
I remember attributing to a stressing period at work the mind fog, chronic fatigue and joint pain when they started.
I still do not know if it would benefit me but I am told, though by surgeons who never performed one, mesh removal is a high-risk surgery. This leads me to seek, if it exists, any option for mesh removal that can contain risk and does not imply losing the rectus muscles and using another mesh as a bridge to achieve abdominal closure.
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I’m sorry for what you’re going through and I hope you can eventually find a solution. Did you happen to have any prior surgery before the mesh was implanted that involved opening the entire abdomen up? From my understanding, and anyone correct me if I’m wrong, little if any adhesions form after mesh is placed in retro rectus fashion, at least from what I have read. Adhesions usually form a lot when mesh is placed inside the abdominal cavity, in contact with the bowel. Even with the abdominoplasty, it still doesn’t involve cutting straight through the peritoneum, so I wouldn’t expect to form such dense adhesions. Again, correct me if I’m wrong.
[USER=”1660″]idoncov[/USER] As far as the systemic symptoms you could for sure be having a reaction to mesh if those were present before mesh implantation. Your symptoms are super similar to idoncov and his experience with the mesh. He’s talked about it on the forum before.
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