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Mesh Does not Substitute for a Correct Technique, and Can Turn a Simple Procedure Into a Complex Disease With a Difficult Solution
Las mallas no suplen una técnica correcta, y pueden convertir un proceso sencillo en una enfermedad compleja de difícil solución
Alfredo Moreno-Egea
Unidad de Pared Abdominal, Hospital Universitario Morales Meseguer, Murcia, Spain
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As their use has become routine, the surgical process has undergone changes in such a way that the mesh has taken the leading role in the procedure. Meanwhile, other steps that had been consolidated after years of experience and were considered essential for avoiding recurrences have been minimized or even forgotten altogether. These include: clear identification and dissection of the inguinal ligament, pubis and posterior floor; treatment of the sac; assessment of the internal inguinal ring; treatment of the cremaster; assessment of sliding over the pubis; etc.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">To illustrate this situation, I present the case of a 65-year-old male, with no medical history of interest or risk factors for deficient healing or immune alterations (no obesity, diabetes, aneurysm; non-smoker; no malnutrition; no liver or kidney failure; etc.), who was referred to us after <span class="elsevierStyleItalic">8 inguinal hernia surgeries and 12 mesh implants</span> in the abdominal wall. The patient had spent the last 6 years undergoing surgery after surgery, without being able to live a normal life. What started out as a small unilateral inguinal hernia turned into a recurring hernia, chronic seroma, fistula, pubic incisional hernia, infraumbilical incisional hernia and, finally, iliac incisional hernia, as well as an abdominal wall that was fibrous, wood-like, insensitive and deformed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient was monitored until the closure of the skin infection. He was made to walk 1<span class="elsevierStyleHsp" style=""></span>h per day, and tomographic reconstruction of the abdominal wall was used (defect 10<span class="elsevierStyleHsp" style=""></span>cm×12<span class="elsevierStyleHsp" style=""></span>cm on the iliac spine, with intestinal content). After confirming the state of the entire abdominal wall, we operated and found the remains of several surgical mesh implants and cavities. Another 2 whole mesh implants measuring 20<span class="elsevierStyleHsp" style=""></span>cm had been rejected and located on top of necrotic tissue (one premuscular on the entire midline and another retromuscular on the upper inguinal area); these mesh patches were totally wrinkled and showed no signs of integration (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The implants were removed and the affected tissue was cleaned. In spite of the situation, we decided to use a containment repair of the entire right hemiabdomen with a low-density, polypropylene, large-pore (3<span class="elsevierStyleHsp" style=""></span>mm), titanium-coated mesh (24<span class="elsevierStyleHsp" style=""></span>g/m<span class="elsevierStyleSup">2</span>) (TiMesh<span class="elsevierStyleSup">®</span>, PdF, Germany). After 24<span class="elsevierStyleHsp" style=""></span>h, the retromuscular drain was withdrawn, followed by the superficial drain after 48<span class="elsevierStyleHsp" style=""></span>h. On the 3rd day, the patient was discharged with no complications. He currently remains asymptomatic and has had no complications or recurrence.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">This case makes us reflect on our use of surgical mesh in abdominal wall surgery. Mesh implants do not avoid recurrences and can cover up an improper technique by an insufficiently trained surgeon. We must remember that the mesh is only a resource that should be implanted with correct technique; the mesh itself is not the technique. In order to avoid recurrences, we must not forget to properly identify the complete inguinal space, perform careful anatomical dissection, and identify and treat all the weak areas, lipomas and hernia sacs of the myopectineal orifice.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3–5</span></a> Fascial repair techniques have been forgotten, but the problem is that, along with them, the need for correct regional dissection has also fallen along the wayside. We cannot trust that a mesh implant, regardless of the type, will be able to resolve all our problems. In coming years, we may see an increase in the number of very complex cases in patients with multi-recurrent hernias and we will have to be prepared to provide a solution. Two lessons can be learned from this case: (1) the need for correct management of mesh techniques, indications and adequate understanding of the properties of the mesh that we are using; and (2) the need for continued training and learning in abdominal wall problems, in which case the possibility of surgical specialization seems prudent.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Moreno-Egea A. Las mallas no suplen una técnica correcta, y pueden convertir un proceso sencillo en una enfermedad compleja de difícil solución. Cir Esp. 2015;93:344–345.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 845 "Ancho" => 1000 "Tamanyo" => 130730 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Physical examination of the patient; the iliac crest and defect have been outlined; the skin is deformed, thickened and presents trophic alterations.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 981 "Ancho" => 1000 "Tamanyo" => 249499 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Detailed image of the abdominal wall showing how the right subcutaneous flap was created, the site of the premuscular rejection, and wrinkled mesh with no integration.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:2 [ "titulo" => "Eventraciones. 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| 2021 May | 18 | 7 | 25 |
| 2021 April | 25 | 17 | 42 |
| 2021 March | 12 | 11 | 23 |
| 2021 February | 19 | 10 | 29 |
| 2021 January | 24 | 13 | 37 |
| 2020 December | 9 | 9 | 18 |
| 2020 November | 8 | 13 | 21 |
| 2020 October | 10 | 6 | 16 |
| 2020 September | 16 | 6 | 22 |
| 2020 August | 15 | 9 | 24 |
| 2020 July | 10 | 8 | 18 |
| 2020 June | 10 | 6 | 16 |
| 2020 May | 11 | 13 | 24 |
| 2020 April | 3 | 3 | 6 |
| 2020 March | 18 | 7 | 25 |
| 2020 February | 9 | 3 | 12 |
| 2020 January | 12 | 6 | 18 |
| 2019 December | 18 | 12 | 30 |
| 2019 November | 10 | 5 | 15 |
| 2019 October | 8 | 10 | 18 |
| 2019 September | 13 | 8 | 21 |
| 2019 August | 8 | 10 | 18 |
| 2019 July | 12 | 10 | 22 |
| 2019 June | 22 | 18 | 40 |
| 2019 May | 96 | 9 | 105 |
| 2019 April | 20 | 9 | 29 |
| 2019 March | 4 | 9 | 13 |
| 2019 February | 12 | 9 | 21 |
| 2019 January | 5 | 2 | 7 |
| 2018 December | 2 | 4 | 6 |
| 2018 November | 7 | 2 | 9 |
| 2018 October | 8 | 4 | 12 |
| 2018 September | 7 | 0 | 7 |
| 2018 August | 2 | 0 | 2 |
| 2018 July | 5 | 3 | 8 |
| 2018 June | 4 | 0 | 4 |
| 2018 May | 3 | 2 | 5 |
| 2018 April | 3 | 0 | 3 |
| 2018 March | 0 | 3 | 3 |
| 2018 February | 12 | 3 | 15 |
| 2018 January | 2 | 5 | 7 |
| 2017 December | 14 | 1 | 15 |
| 2017 November | 7 | 1 | 8 |
| 2017 October | 10 | 2 | 12 |
| 2017 September | 6 | 2 | 8 |
| 2017 August | 10 | 5 | 15 |
| 2017 July | 11 | 2 | 13 |
| 2017 June | 21 | 3 | 24 |
| 2017 May | 12 | 4 | 16 |
| 2017 April | 11 | 2 | 13 |
| 2017 March | 19 | 44 | 63 |
| 2017 February | 14 | 3 | 17 |
| 2017 January | 13 | 5 | 18 |
| 2016 December | 17 | 9 | 26 |
| 2016 November | 32 | 4 | 36 |
| 2016 October | 37 | 13 | 50 |
| 2016 September | 31 | 4 | 35 |
| 2016 August | 19 | 4 | 23 |
| 2016 July | 13 | 2 | 15 |
| 2016 June | 19 | 5 | 24 |
| 2016 May | 30 | 11 | 41 |
| 2016 April | 33 | 10 | 43 |
| 2016 March | 34 | 17 | 51 |
| 2016 February | 16 | 7 | 23 |
| 2016 January | 21 | 3 | 24 |
| 2015 December | 23 | 9 | 32 |
| 2015 November | 28 | 6 | 34 |
| 2015 October | 23 | 7 | 30 |
| 2015 September | 23 | 3 | 26 |
| 2015 August | 11 | 7 | 18 |
| 2015 July | 2 | 1 | 3 |
| 2015 June | 0 | 1 | 1 |
| 2015 May | 1 | 2 | 3 |
Show all
