Plastic treatment for giant pseudocyst after incisional hernia mesh repair: a case report and comprehensive literature review

Marius Kryzauskas; Vytautas Lipnickas; Simonas Uselis; Donatas Danys; Kestutis Strupas

doi:10.1515/med-2018-0079

Article Open Access

Plastic treatment for giant pseudocyst after incisional hernia mesh repair: a case report and comprehensive literature review

Marius Kryzauskas , Vytautas Lipnickas , Simonas Uselis , Donatas Danys and Kestutis Strupas

Published/Copyright: December 24, 2018

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From the journal Open Medicine Volume 13 Issue 1

Abstract

Giant pseudocyst is a very rare complication after incisional hernia repair with mesh. We present a case of 54-year-old male patient with a giant pseudocyst, which developed after incisional hernia repair with mesh. A patient was discussed during multidisciplinary team meeting and operative treatment was suggested to the patient. Extirpation of the cyst was accomplished. There was observed no defect in the abdominal wall. The patient was discharged on the 7th postoperative day. Ultrasonography two weeks after discharge again showed fluid collection. There were 6 aspirations every week starting from 400 ml serous fluid at the beginning and 60 ml at the end. There were no signs of fluid collection one month after the last aspiration. Surgical plastic treatment of giant pseudocyst after incisional hernia mesh repair is safe and feasible despite its low prevalence.

Keywords: Hernia repair; Giant pseudocyst; Plastic treatment

1 Introduction

Incisional hernia mesh repair is a common routine operation worldwide. One of the most commonly occurring complications is postoperative seroma, others such as hematoma or subcutaneous abscess are less common [1]. Formation of postoperative seroma varies widely from 3 to 100% with a peak presentation at the 7^th postoperative day. Moreover, guidelines did not distinguish between clinically significant and asymptomatic seromas [2]. Recent prospective study revealed 100% incidence of seroma after mesh repair, following with all and complete spontaneous resolution within 90 days after initial surgery [3]. Meanwhile, formation of chronic and greater in size subcutaneous cysts or pseudocysts are exceedingly rare after these operations. Only 35 cases have been presented worldwide in single cases or case series from the 1993 up to date (Table 1). Incidence of small case series varies from 0.45 % to 0.8 % suggesting its rare prevalence or lack of reports in scientific literature [4].

Table 1

Case reports of pseudocysts after hernia repair with mesh

Year	First author	Case no	Age	M/F	Hernia type	Size/volume (cm/ml)	Mesh	Treatment	Onset time
1993	Waldrep [1]	1	62	F	Incisional	20 x 15	Marlex	Excision	NM
		2	78	F	Incisional	13 x 7	Marlex	Excision	12
1998	Arya [5]	3	74	F	Incisional	17 x 12	Prolene	Excision	2
2004	Ogunbiyi [6]	4	37	F	Incisional	25 x 18	Prolene	Excision	24
		5	68	F	Spiegel	NM	Prolene	Excision	12
		6	66	F	Incisional	NM	Prolene	Excision	4
		7	46	F	Incisional	NM	Prolene	Excision	3
		8	83	M	Incisional	NM	Prolene	Excision	3
2006	Mayagoitia [19]	9	60	F	Incisional	20 x 25	Prolene	Excision	2
		10	77	F	Incisional	25 x 30	Prolene	Excision	4
2006	Mehrotra [13]	11	56	F	Incisional	32 x 25	Prolene	Laparoscopic excision	1
2007	Sahin-To´th [11]	12	31	F	Incisional	NM	Prolene	Excision	4
		13	44	M	Incisional	NM	Prolene	Excision	8
		14	57	F	Incisional	NM	Prolene	Excision	25
		15	78	F	Incisional	NM	Prolene	Excision	15
		16	70	M	Incisional	NM	Prolene	Excision	5
2008	Narayanan [14]	17	42	F	Incisional + abdominoplasty	2000 ml	Prolene	Excision	6
2008	Hoefkens [15]	18	79	F	Incisional	20 x 24	Prolene	Excision	NM
2008	Omundsen [16]	19	49	F	Incisional	4 x 3	Prolene	Debridment	4
2011	Ielpo [4]	20	46	F	Incisional	16 x 10	Prolene	Excision	7
		21	58	M	Incisional	21 x 18	Prolene	Excision	11
		22	79	F	Incisional	12 x 9	Prolene	Excision	19
		23	55	F	Incisional	25 x 28	Prolene	Excision	15
		24	74	F	Incisional	13 x 10	Prolene	Refused surgery	21
		25	83	F	Incisional	17 x 12	Prolene	Refused surgery	5
		26	63	F	Incisional	11 x 13	Prolene	Aspirations only	4
2012	Ielpo [9]	27	63	M	Inguinal	10 x 6	Prolene	Excision (partial)	5
		28	61	M	Inguinal	11 x 5	Prolene	Excision (partial)	7
2013	Salgaonkar [7]	29	71	F	Incisional	25 x 20	NM	Excision	3
		30	56	F	Incisional	1300 ml	Prolene	Excision	10
2014	Saavedra-Perez [8]	31	79	F	Incisional	31 x 19	PTFE*	Excision	NM
2014	Mantelou [12]	32	78	F	Incisional	18 x 13	Prolene	Excision	NM
2014	Vasilakis [17]	33	52	M	Incisional	10 x 17	NM	Excision (partial)	NM
2015	Narkhede [18]	34	36	F	Incisional	24 x 15	Prolene	Excision	18
2016	van Loon [10]	35	63	M	Inguinal	16	NM	Laparoscopic fenestration	6
2017	Current report	36	54	M	Incisional	17 x 15	Prolene	Excision	6

NM – not mentioned, *PTFE – polytetrafluoroethylene

2 Case report

We present the case of a 54-year-old obese (body mass index 33.7 kg/m²), diabetic male patient presenting with a large palpable mass in the anterior abdominal wall (Figure 1). An anamnesis of the disease starts with a midline laparotomy incision which was performed due to descending colon tumour in August 2014. Final pathological diagnosis revealed well differentiated (G2) pT4bN0 mucinous adenocarcinoma without distant metastases. An adjuvant chemotherapy using FOLFOX4 regimen was admitted. There was no evidence of local recurrence or disease spread observed two years after primary operation. Nevertheless, an incisional hernia was confirmed during routine check-up. A patient underwent an onlay polypropylene mesh repair for an incisional hernia in September 2016. Later, the abdominal mass developed gradually over the several months before the presentation to the outpatient department of our hospital. All laboratory investigations were within normal parameters. A computed tomography (CT) scan of the abdomen was performed to establish the diagnosis and rule out tumour recurrence. CT indicated 170 x 153 x 217 mm well-defined cystic lesion (~15 HU) with thickened partitions and flat contact with muscles of the anterior abdominal wall (Figure 2). An aspiration of the 2500 ml dark coloured cystic content (serohemorrhagic fluid) was performed. Nevertheless, the decrease in volume was temporary and one month later cystic lesion was the same size like before aspiration. A multidisciplinary team decision was made and operative treatment was suggested to the patient. Extirpation of the cyst was accomplished and no defect in the abdominal wall was observed (Figure 3, 4). Two drains were placed in residual place, which were removed on the 2^nd postoperative day. After removal of the excess of the skin, the subcutaneous layer and skin were sutured by individual stitches (Figure 5). The removed specimen was sent for pathological evaluation (Figure 6a, 6b), which revealed granulomatous inflammation in fibrotic wall of the pseudocyst. There was no growth of bacterial cultures in the fluid. The patient was discharged on the 7^th postoperative day. Ultrasonography two weeks after discharge again showed fluid collection. There were 6 aspirations every week starting with 400 ml serous fluid at the beginning and 60 ml at the end.

Figure 1

Presentation of the abdomen before the operation

Figure 2

Giant cystic lesion on the computed tomography scan

Figure 3

Excision of the encapsulated seroma in progress

Figure 4

Anterior abdominal wall after encapsulated seroma excision

Figure 5

Anterior abdominal wall after wound closure

Figure 6

Removed specimen

No hernia recurrence, seroma or other complication was observed one month after the last aspiration.

Ethical approval: The research related to human use has been complied with all the relevant national regulations, institutional policies and in accordance the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

Informed consent: Informed consent has been obtained from the individual included in this study.

3 Discussion

There are either no, or non-specific, symptoms in early stages of the disease. Usually, patients are admitted to hospital due to abdominal mass, which had increased in the course of a few months [1,5,6]. A medical history of previous incisional hernia repair using polypropylene mesh is presented the majority of these cases [4,7,8], less commonly after inguinal hernioplasty [9,10]. A tense cystic palpable mass with fluctuation is presented during clinical examination. Additionally an ultrasonography reveals fluid cyst with thick external wall and internal septations with or without debris inside [4,6,11]. Abdominal CT confirms pseudocystic appearance and clarifies extraperitoneal location ruling out recurrent incarcerated incisional hernia from differential diagnosis [4,7, 8, 9, 12]. While prevalence of giant pseudocyst is low, etiology also remains unclear. Other authors suggest manifestation of simple seroma or complication of postoperative hematoma. Formation of seroma is associated with disrupted lymphatic drainage due to intraoperative dissection of subcutaneous space. Meanwhile, postoperative hematomas sometimes tend to organize and clinically appear as gigantic pseudocyst [4,5,9]. Onlay technique was used in most cases as it reported. Thus, prosthetic mesh may support inflammatory process in postoperative course [12].

Worthy of mention is that onset time from initial hernioplasty to diagnosis of pseudocyst varies extremely, from

1 to 25 months. The diameter of the pseudocysts varies from 13 x 7 cm to 32 x 25 cm in reviewed cases, respectively. Predominantly giant pseudocysts occur in females (27) in comparison with males (9) (Table 1).

Conservative treatment was fruitless or even not considered due to thick wall, internal septations and dense content of the cyst in presented cases. Surgical treatment appears to be simple and effective for giant pseudocysts. No recurrence was reported during postoperative follow-up period in all cases.

4 Conclusion

Surgical treatment of giant pseudocyst after incisional hernia mesh repair is safe and feasible despite its low prevalence.

Disclosure statement: No potential conflict of interest was reported by the authors.

References

[1] Waldrep, D. J., Shabot, M. M., Hiatt, J. R. Mature fibrous cyst formation after Marlex mesh ventral herniorrhaphy: a newly described pathologic entity. Am Surg, 1993, 59, 716-718Search in Google Scholar

[2] Bittner, R., Bingener-Casey, J., Dietz, U., Fabian, M., Ferzli, G. S., Fortelny, R. H., Köckerling, F., Kukleta, J., LeBlancm K., Lomanto, D., et al.. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society [IEHS])-Part 2. Surg Endosc, 2014, 28, 353-37910.1007/s00464-013-3171-5Search in Google Scholar PubMed PubMed Central

[3] Susmallian, S., Gewurtz, G., Ezri, T., Charuzi, I. Seroma after laparoscopic repair of hernia with PTFE patch: is it really a complication? Hernia, 2001, 5, 139-14110.1007/s100290100021Search in Google Scholar PubMed

[4] Ielpo, B., Cabeza, J., Jimenez, D., Delgado, I., Torres, A. J. Abdominal pseudocyst complicating incisional hernia repair: our experience and literature review. Hernia, 2011, 15, 233-23710.1007/s10029-010-0640-9Search in Google Scholar PubMed

[5] Arya, N., Batey, N. R. Pseudocyst formation after mesh repair of incisional hernia. J R Soc Med, 1998, 9, 647-64910.1177/014107689809101214Search in Google Scholar PubMed PubMed Central

[6] Ogunbiyi, S. O., Morris-Stiff, G., Sheridan, W. G. Giant mature cyst formation following mesh repair of hernias: an underreported complication? Hernia, 2004, 8, 166-16810.1007/s10029-003-0201-6Search in Google Scholar PubMed

[7] Salgaonkar, H. P., Gouda, B., Behera, R. R., Katara, A., Bhandarkar, D. Encapsulated seroma following incisional hernia repair. AWRJ, 2013, 1, 13-16Search in Google Scholar

[8] Saavedra-Perez, D., Benarroch, G., Vidal, O., Garcia-Valdecasas, J. C. Giant Abdominal Pseudocyst: A Rare Complication of Incisional Hernia Repair With Mesh. CIR ESP, 2014, 92, 28310.1016/j.cireng.2013.09.024Search in Google Scholar

[9] Ielpo, B., Lapuente. F., Martin, P., Acedo, F., San Roman, J., Corripio, R., Vazquez, R., Fernandez-Nespral, V. First cases of giant pseudocyst complicating inguinal hernia repair. Hernia, 2012, 16, 589-59110.1007/s10029-011-0786-0Search in Google Scholar PubMed

[10] van Loon, Y. T., Ibelings, M. S. Laparoscopic Fenestration of a Giant Pseudocyst after Totally Extra Peritoneal Inguinal Hernia Repair. Case Rep Surg, 2016, Article ID 986764510.1155/2016/9867645Search in Google Scholar PubMed PubMed Central

[11] Sahin-To´th, G., Hala´sz, T., Viczia´n, C., Ola´h, T. Late complication after mesh repair of incisional hernias: pseudocyst formation. Magy Seb, 2007, 60, 293-296Search in Google Scholar

[12] Mantelou, A. G., Georgiou, G. K., Harissis, H. V. Giant pseudocyst of the anterior abdominal wall after incisional hernia mesh repair: a rare case report. Hernia, 2014, 18, 141-14410.1007/s10029-013-1144-1Search in Google Scholar PubMed

[13] Mehrotra, P. K., Ramachandran, C. S., Goel, D., Arora, V. Giant pseudocyst of the anterior abdominal wall following mesh repair of incisional hernia: a rare complication managed laparoscopically. Hernia, 2006, 10, 192-19410.1007/s10029-005-0025-7Search in Google Scholar PubMed

[14] Narayanan, C. D., Dinesh, N. Abdominal wall pseudocyst following abdominoplasty after postmastectomy radiation therapy. Hernia, 2008, 12, 545-54710.1007/s10029-008-0343-7Search in Google Scholar PubMed

[15] Hoefkens, M. F., Vles, W. J. A giant pseudocyst following repair of an incisional hernia by a propylene mesh. Ned Tijdschr Geneeskd, 2008, 152, 216-220Search in Google Scholar

[16] Omundsen, M., Zargar, H., Purchas, S. Giant cyst: an underreported complication of hernia mesh repairs? ANZ J Surg, 2008, 78, 822-82310.1111/j.1445-2197.2008.04664.xSearch in Google Scholar PubMed

[17] Vasilakis, V., Cook, K., Wilson, D. Surgical resection and scarification for chronic seroma post-ventral hernia mesh repair. Am J Case Rep, 2014, 15, 526-52910.12659/AJCR.891346Search in Google Scholar PubMed PubMed Central

[18] Narkhede, A., Marda, S. S., Balani, A., Alwala, S., Shah, M., Zanke, R., Sarjare, S., Kumar, A. Giant Abdominal Wall Pseudocyst with Recurrent Incisional Hernia Following Mesh Repair Hernioplasty. J Gastrointest Dig Syst, 2015, 5, 34910.4172/2161-069X.1000349Search in Google Scholar

[19] Mayagoitia, J.C., Almaraz, A., Dı´az, C. Two cases of cystic seroma following mesh incisional hernia repair. Hernia, 2006, 10, 83-8610.1007/s10029-005-0002-1Search in Google Scholar PubMed

Received: 2018-01-03

Accepted: 2018-09-17

Published Online: 2018-12-24

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.

Articles in the same Issue

https://doi.org/10.1515/med-2018-0079

Keywords for this article

Hernia repair; Giant pseudocyst; Plastic treatment

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