CASE REPORT

Ventral hernia mesh tack causes liver hemorrhage

G. Baltazar • K. Coakley • A. Badiwala •

A. Chendrasekhar

Received: 1 December 2011 / Accepted: 30 September 2012 / Published online: 18 October 2012

� Springer-Verlag France 2012

Abstract

Introduction The laparoscopic approach is an increas-

ingly popular option for ventral hernia repair. In the wake

of this new technology, unexpected complications have

been reported.

Case presentation We present the case of a patient who

developed a liver laceration and hemorrhage after a mesh

tacking device partially dislodged subsequent to ventral

hernia repair. The patient underwent exploratory laparot-

omy, liver hemostasis and removal of the offending tack.

Discussion Our patient partially dislodged a mesh tacking

device likely after violent coughing during a bout of

pneumonia. The exposed blade caused a liver laceration

and hemorrhage. Few other unexpected complications of

the use of mesh tacking devices have been noted in the

literature. Tackless hernia repair has also been described.

Conclusion Laparoscopic ventral hernia repair with tacks

may have unexpected complications of which the surgeon

should be aware and advise patients. Our patient developed

a liver laceration and symptomatic hemorrhage after par-

tially dislodging a hernia mesh tack. Further research into

tackless hernia repair may be beneficial. A low long-term

recurrence rate would demonstrate if tackless hernia repair

is a viable option.

Keywords Ventral hernia � Laparoscopic hernia mesh �Hernia tack � Liver laceration

Introduction

Ventral hernias are defects of the abdominal wall fascia

through which properitoneal or intra-abdominal contents

may protrude. Associated primarily with previous surgical

incisions, ventral hernias account for approximately 10 %

of all hernias [1]. Often benign entities, if left untreated,

ventral hernias may incarcerate, and their contents may

develop life-threatening ischemia [2].

Most frequently repaired with mesh, a low-tension

repair is considered the standard of care for treatment for

ventral hernias [1]. Although open repair is believed to be

the most widely used approach, the total number of lapa-

roscopic hernia repairs is increasing, particularly among

reducible inguinal hernias [4].

Some benefits of laparoscopic ventral hernia repair have

been described in the literature, in particular shortened hos-

pital stay [3]. However, unforeseen complications are also

being reported. For example, reduced post-operative pain is

expected with less-invasive operations. However, some

authors note that pain may be worse or prolonged after lap-

aroscopic repairs [5]. Some complications have been noted

particularly related to the use of mesh tacking devices [6–8].

We present the case of a partially dislodged mesh

tacking device causing liver laceration and acute, symp-

tomatic hemorrhage. We then discuss the risks of tacks

with laparoscopic ventral hernia repair (LVHR) and the

potential benefits of tackless LVHR.

Case report

A 75-year-old obese Hispanic female presented to the

emergency department of an urban community hospital

complaining of 3 days of dyspnea, cough, fever and

G. Baltazar � K. Coakley (&) � A. Badiwala �A. Chendrasekhar

Department of Surgery, Wyckoff Heights Medical Center,

Brooklyn, NY, USA

e-mail: kathleencoakley@gmail.com

123

Hernia (2013) 17:679–682

DOI 10.1007/s10029-012-1001-7

abdominal pain. The abdominal pain developed after a

coughing fit and was associated with nausea and loose

stools. She has a medical history of hypertension, a midline

laparotomy for hysterectomy for bleeding fibroids, multiple

cataract surgeries and a laparoscopic ventral hernia repair.

On admission, the patient was febrile, hypotensive and

tachycardic with poor skin turgor. Her abdominal exam

revealed diffuse tenderness, a healed midline laparotomy

and scars from a laparoscopic ventral hernia repair. A chest

X-ray revealed a left pleural effusion and underlying

pneumonia. A contrast CT of the abdomen and pelvis

additionally revealed a large LVHR mesh with reactive

changes related to the right upper quadrant edge of the

mesh. An abdominal sonogram was unremarkable.

She was treated for pneumonia, dehydration and sepsis.

On hospital day two, her pulmonary status improved while

her abdominal pain acutely worsened and she vomited

multiple times. On the same day, she developed tachycar-

dia into the 120 s and a drop in hematocrit from 39.7 % on

admission to 20.3 %.

A repeat CT scan was performed and revealed approx-

imately one liter of blood in the abdomen and pelvis

(Fig. 1). Due to ongoing tachycardia and worsening

abdominal pain, the patient was brought to the operating

room for an exploratory laparotomy.

Intra-operatively, the hematoma was evacuated, four

quadrants were packed and extensive lysis of adhesions

was performed to effectively examine each quadrant. The

only bleeding lesion was a 6 cm long by 1 cm deep liver

laceration on the anterior surface of Couinaud segments II

and III, in the area of a partially dislodged titanium Pro-

Tack. The tack was still within the mesh, but no longer

fixed to abdominal wall, allowing the sharp edge of the

tack to be free, adjacent to the liver. The laceration seen on

the liver was consistent in location and character with

position, length and angle of the exposed blade of the tack.

The offending tack was sharply removed from the mesh,

and hemostasis was assured at the liver laceration.

The patient tolerated the procedure well, and after res-

olution of her pneumonia and return of bowel function, she

was discharged home on post-operative day 6.

Discussion

Increased intra-abdominal pressure from coughing sec-

ondary to pneumonia likely partially dislodged the tack,

exposing its blade and lacerating the liver. High intra-

abdominal pressures from obesity alone may be enough to

dislodge an intra-abdominal mesh, [4] and additional forces

such as coughing would increase this potential [10].

Because of the characteristic short length and 5 mm

diameter of the tack’s blade, a small grade-one liver lac-

eration or a parenchymal defect less than 1 cm deep would

be expected from direct tack trauma. However, the 6 cm

length and 1 cm depth imply that the tack lacerated addi-

tionally longitudinally and deeply due to a sawing-type of

motion related to the patient’s breathing. In addition to

causing a parenchymal defect, this repeated trauma pre-

vented hemostasis. The resulting hemorrhage led to wors-

ening abdominal discomfort, nausea, vomiting, anemia and

persistent tachycardia.

Hemorrhage after LVHR may occur in up to 36 % of

patients. However, these are most often secondary to

inadvertent puncture of vessels in the abdominal wall by

trocar insertion or missed large vessel injury in the hernia

contents [1]. Hemorrhage can be evaluated with CT or

ultrasound to rule out abscess, but generally, these hema-

tomas are benign and are treated with warm compresses,

observation and the use of an abdominal binder [3]. To our

knowledge, there have been no reports of hemorrhage after

LVHR due to liver laceration by a mesh tacking device.

Fig. 1 a Abdominal CT scan ‘‘scout’’ film revealing a large PTFE ventral hernia mesh with metal tacks. b Dislodged mesh tack and perihepatic

hematoma. c Magnification of dislodged mesh tack, demonstrating liver laceration

680 Hernia (2013) 17:679–682

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Other complications from a mesh tacking device are rare

but have been reported. Persistent post-LVHR pain beyond

6–8 weeks is often considered secondary to a mesh tack

directly damaging a nerve and is a rare complication found

in 1–2 % of patients [11]. Injections of local anesthesia or

excision of tacks from the area of pain with repeat lapa-

roscopy effectively eliminate this pain. In 2003, LeBlanc

reported two hernias that occurred through fascia likely

disrupted by mesh tacking devices [7]. A recent study on

pigs, revealed that compared to sutures, spiral tacks lead to

more numerous and more dense adhesions [6]. In 2006,

Withers reported a case of volvulus that rotated around an

adhesion to a spiral tack subsequent to an inguinal hernia

repair [8].

Some authors suggest that minimal use of strategically

placed tacks with counter-pressure on the abdominal wall

combined with appropriately spaced sutures leads to the

strongest fixation and lowest recurrence rates in LVHR

[12]. However, it may be possible to adhere meshes to the

abdominal wall without any penetrating devices. Recent

articles have touted the effectiveness of tackless repair in

other types of hernias by using either no fixative, or the

procoagulant Tisseel as glue [9, 13–15]. For LVHR, a

recent randomized clinical trial revealed that mesh fixation

with fibrin sealant is associated with less acute post-oper-

ative pain and discomfort alongside shorter convalescence

compared to tack fixation [16]. In addition, an animal

model evaluation of mesh placement showed fixation

strength with only fibrin sealant was inadequate for

absorbable barrier-coated and select non-absorbable

meshes; sutures added to the combination may offer suf-

ficient fixation [17]. To our knowledge, no studies have

evaluated the long-term recurrence rate of any type of

hernia, subsequent to tackless repair. Minimal utilization

necessary to assure fixation and repair as well as deep

fixation of these tack devices with adequate counter-pres-

sure is likely to decrease risk of tack laceration or bowel

erosion complications.

Beyond the advantages and drawbacks of open versus

laparoscopic repair, intra-peritoneal placement of mesh

cannot be regarded as entirely benign. Halm et al. showed

intra-peritoneal mesh placement alone has complications in

subsequent abdominal surgery. Intra-peritoneal and pre-

peritoneal meshes were related to complication rates after

subsequent surgical interventions. Small bowel resections

were necessary in 21 % of the intra-peritoneal group (8/39)

versus 0 % in the preperitoneal group [18].

The complex pathogenesis of our patient’s injury

implies that her injury may be an isolated incident. How-

ever, the dislodgement of a mesh tacking device is a known

entity, and as the devices are designed to incise, there is

definite danger if a free sharp edge is exposed to abdominal

contents.

Conclusion

Our case of a mesh tack causing liver laceration adds to the

knowledge that laparoscopic ventral hernia repair may not

be as benign as its less-invasive nature may lead the sur-

geon to believe. The effectiveness of mesh tacking devices

has been debated in the literature, and few unexpected

complications have become associated with their use. It is

important in light of untoward outcomes of tack repair to

perform further research into tackless LVHR. Although

tackless hernia repair is a possibility, it remains untested

for long-term recurrence.

Conflict of interest The authors declare no conflict of interest.

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