Adam Howard

Conservative management of an infected laparoscopic hernia mesh: A case study

INTRODUCTION A dreaded complication of laparoscopic hernia repair is infection of the mesh. Traditionally mesh infection is managed by surgical removal of the mesh, an extensive procedure resulting in high re-herniation rates. A technique to treat such infections whilst salvaging the mesh is sorely needed. We describe a case in which a laparoscopic mesh infection was treated solely with drainage, parenteral antibiotics and antibiotic irrigation of the mesh. PRESENTATION OF CASE A 65 year old gentleman presented 11 months post laparoscopic repair of an inguinal hernia with malaise and an uncomfortable groin swelling. Computed tomography scanning revealed a collection surrounding the mesh which was drained and cultured to show heavy growth of Staphylococcus aureus. A pigtail drain on continuous drainage was inserted and kept in situ for 7 weeks. The patient received one week of intravenous flucloxacillin and two gentamycin irrigations through the drain as an inpatient. He then received 6 weeks of oral flucloxacillin and bi-weekly saline flushes through the drain in the community. By 12 weeks an ultrasound scan showed resolution of the collection. At 7 months he remains clinically free from recurrence. DISCUSSION Here we report a novel conservative method used to treat a hernia mesh infection, preserve the mesh and avoid major surgery. Other reports exist suggesting variations in conservative methods to treat mesh infections, however ours is by far the most conservative. CONCLUSION Clearly, further research is required to identify which method is most effective and in which patients it is likely to be successful.

Successful laparoscopic repair of refractory type Ia endoleak after endovascular abdominal aortic aneurysm repair.

Type I endoleaks associated with sac enlargement after endovascular abdominal aortic aneurysm repair mandate urgent intervention. Endoluminal treatments are generally considered first, but when these fail, open surgery has been advocated as a last resort. Open surgery is associated with significant mortality and morbidity, and thus, approaches that reduce this risk would be of interest. We report a successful case of laparoscopic treatment of a refractory type Ia endoleak after endovascular abdominal aortic aneurysm repair in an 83-year-old man.

Introduction of laparoscopic abdominal aortic aneurysm repair.

The aim was to review a consecutive series of patients treated with laparoscopic abdominal aortic aneurysm (AAA) repair. These patients were compared with patients having elective open AAA repair.

Comment on: Conservative management of an infected laparoscopic hernia mesh: A case study

INTRODUCTION We recently published an article in this journal describing the successful conservative treatment of a patient with an infected laparoscopically inserted hernia mesh using gentamycin flushes via a pig-tail drain and long term oral antibiotics. This prevented the need for major reconstructive surgery. However, 3 months after we published our report, the patient re-presented with symptoms of a recurrence of infection. PRESENTATION OF CASE Seven months after stopping oral antibiotics, our patient represented with fever and swelling and redness over his left sided inguinal hernia mesh. This mesh had to be surgically removed. The procedure was laparoscopic and showed infection confined to the central 5 cm of the mesh. Microbiology culture results were the same as on initial presentation. DISCUSSION The microbiology results suggest that it is likely that the infection was never fully eradicated and that our intervention merely kept the infection at bay. Once long term antibiotics were stopped it is likely that the infection was able to eventually recur. CONCLUSION Consequently, we have been unable to show that our method of conservative management of infected hernia meshes is effective to prevent long term recurrence of infection.

Laparoscopic aortic surgery (Br J Surg 2010; 97: 1153-1154).

Sir We read with interest the well conducted randomized study by Braga and colleagues comparing laparoscopic versus open left colonic resection. There is now a consistent body of literature showing that laparoscopic colonic surgery, although associated with longer operating times, contributes towards shorter length of hospital stay, equivalent or improved morbidity, and improved early quality of life compared with open colonic resection. In a previous study by the same group, the increased hospital costs in the laparoscopic surgery group were attributed to the higher cost of laparoscopic instrumentation and longer operating times1. In the present study, the authors suggest that performing the anastomosis and splenic flexure takedown laparoscopically resulted in reducing the invasiveness of the approach. This is in contrast to their previous study on right colectomy where the bowel division and ileocolonic anastomosis was done extracorporeally and the benefits of the laparoscopic approach were not as profound. We are not convinced that bowel division and anastomosis carried out extracorporeally necessarily decreases the benefit of the laparoscopic approach. Not discussed in this article is the use of hand-assisted laparoscopic surgery (HALS) for colonic resection, where the division and anastomosis is often done extracorporeally2. HALS has been shown to produce similar shortand long-term clinical outcomes, as well as potentially decreasing the rate of conversion compared with the standard laparoscopic technique3 – 5. The most important benefit of HALS seems to be a decreased duration of operation, while maintaining the benefits of a minimally invasive approach5. Marcello and colleagues2 noted a time saving of 28 min for left colectomy and 51 min for total colectomy. There is possibly also a reduction in the need for instruments in HALS, although this has not been investigated in any of the studies. We therefore suggest that in selected patients it may be beneficial to employ HALS to decrease the operating time as well as the rate of conversion. This will be associated with a decreased hospital cost of laparoscopy overall, and allow the cost–benefit analysis to shift further in favour of the laparoscopic compared with the open technique. A. Sarin, J. W. Milsom and P. J. Shukla Surgery, Division of Colorectal Surgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA (e-mail: jwm2001@med.cornell.edu) DOI: 10.1002/bjs.7321

A case of hepatic, renal and duodenal penetration by a Celect inferior vena caval filter

Inferior vena caval (IVC) filters are used as a mechanical option for the treatment of venous thromboembolism (VTE) when standard anticoagulation therapy is either contraindicated or VTE recurs despite adequate anticoagulation. Filters are not without risk, however. Reported complications include filter migration and fracture of filter components, leading to IVC rupture and penetration into pericaval tissues (notably kidney, heart, pericardium, thoracic cavity, liver, bowel and aorta). Here we describe an extreme case of multiple organ penetration by a standard Celect caval filter.