Incisional Hernia Repair among Reproductive Age Women

Introduction

There should be some guidelines if any surgeon opts for mesh application in reproductive age group women, especially if she has not completed her family. Or better to go for a composite and / or extra peritoneal mesh application to prevent intraperitoneal or bowel complications, so that a gynaecologist going for an elective LSCS should not come out with intestinal resection-anastomosis!

Case History

A lady aged 31 years, gravida-2, para-1, living-1, with previous LSCS was admitted for safe confinement at 38 weeks of gestation. There was no history of bleeding or leaking per vaginum or pain lower abdomen and she perceived fetal movement well. She was a booked case and had regular antenatal check-ups at SRMS IMS. On obstetric history, she had undergone an emergency LSCS in her first pregnancy, 5 years back at private nursing home, indication being oligohydramnios with fetal distress in labour via midline infra-umbilical vertical incision. 1 year later, she developed incisional hernia for which laparoscopic mesh fixation was done (papers NA). After 4 years she again conceived, and was in regular follow-up. The couples were quite worried in this pregnancy as their first child had delayed milestones, and so they had undergone all suggested biochemical and sonographic soft-tissue markers to rule out any genetic abnormality in this pregnancy. On examination, her vitals, local and systemic examination were within normal limits. So she was taken up for elective LSCS at 38 weeks when she developed obstetric cholestasis, keeping her previous obstetric outcome in mind.

Operative details – Under spinal anesthesia (later converted into GA), abdomen opened through right paramedian vertical incision. While opening the peritoneum, it was found to be badly adherent to a thick firm-to-hard opaque mesh beneath it all over so that no mesh-free area could be found out (?intraperitoneal) and chances of bowel adherent to it could not be ruled out. However, after struggling for few minutes, a fold was held and nick was given. While extending the incision it was found that at upper end of incision, an ileal loop which was badly adherent to mesh has been kicked in. Lower down, uterus was also adherent to anterior abdominal wall along with bladder. Adhesions were separated and LSCS done. An alive term female baby delivered by vertex, cried at birth. Placenta and membranes taken out completely and uterus closed in layers. This was followed by gentle exploration of abdominal cavity with the help of surgeon. It was found that a big (15X 10 cm) prolene mesh was attached intraperitoneal all-over with tackers and prolene sutures, and there were multiple thick adhesions between mesh and lower intestinal loops especially in the upper part. Besides there were multiple inter bowel adhesions present. While doing adhesiolysis of bowel loops from mesh multiple tears developed in ileum. Anyhow, mesh was removed due to high probability of getting infection, inter bowel adhesions separated and a portion of multiple perforated ileal loop resected and anastomosed. Hemostasis secured, intraperitoneal drain given and abdomen closed in layers with prolene. 1 unit B.T. done intra-operative and post-op she was kept in surgical HDU with continuous Ryle’s tube drainage. Recovery period was uneventful except that she had features of aspiration pneumonia at left basal lungs. Liquid diet was started from post-op day 5 followed by soft diet and drain removed on post-op day 14 when serous output minimized.

Discussion

Repair of incisional hernias is best achieved through insertion of prosthetic mesh either by open method or via laparoscopic [1]. Surgical meshes used in laparoscopic and open hernia are available in different synthetic materials such as polyester, polypropylene, composite materials and biological meshes. It is found that intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery and has been found to be associated with more adhesion formation, abdominal pain and discomfort [2]. The use of composite mesh with anti-adhesive coatings will reduce mesh adhesion related complications and prove beneficial in future of abdominal wall surgery. Intraperitoneal mesh positioning seems inadvisable in young females of reproductive age group, if better alternatives are available. However if intraperitoneal mesh positioning is inescapable like in laparoscopic incisional hernia repair, composite meshes are advisable combining minimal adhesion formation and optimal tissue ingrowth [3].