Near-fatal small bowel ischaemia secondary to sacrocolpopexy mesh

Abstract

A 74-year-old woman presenting with acute abdominal pain underwent surgery for suspected small bowel ischaemia. At laparotomy, a sacrocolpopexy mesh in the pelvis, which had been inserted 8 years previously, was found to be causing strangulation of a 2-m length of the small bowel. Following resection and primary anastomosis, the patient spent several days in intensive care before her eventual discharge. This unusual life-threatening complication should be considered in patients presenting with abdominal pain even many years following abdominal sacrocolpopexy.

Background

Although gastrointestinal complications following sacrocolpopexy are well recognised, life-threatening bowel ischaemia as a result of intraperitoneal mesh placement has not been previously described. Awareness of this complication, which in this case developed several years postoperatively, supports retroperitoneal sacrocolpopexy mesh placement and should be considered in patients presenting with acute abdominal pain following the procedure.

Case presentation

A 74-year-old woman presented to the hospital with an 8 h history of sudden-onset central abdominal pain and vomiting. Her medical history included ischaemic heart disease, hypertension and type 2 diabetes mellitus. She had undergone an uncomplicated abdominal sacrocolpopexy using a polypropylene mesh 8 years previously, following a vaginal hysterectomy for uterine prolapse. On admission, the patient was tachycardic and hypotensive, with a base deficit of 7.6 mmol/l and a lactate of 3.7 mg/dl. ECG showed sinus tachycardia. Examination revealed diffuse abdominal tenderness with no guarding or rigidity, and reduced bowel sounds.

In the first 2 h following admission, the patient deteriorated, with worsening pain and progressive hypotension. A repeat arterial blood gas showed a base deficit of 12.4 mmol/l and a lactate of 18 mg/dl.

Investigations

An abdominopelvic CT scan in the emergency department demonstrated free intraperitoneal fluid and small bowel thickening consistent with possible ischaemia (figure 1). Although not reported initially, subsequent inspection of the CT scan identified the close proximity of the sacrocolpopexy mesh to the affected loops of the small bowel.

Figure 1.

Sagittal CT showing sacrocolpopexy mesh (highlighted in red) and multiple fluid-filled small bowel loops with wall thickening, consistent with ischaemia (yellow arrows).

Treatment

An emergency laparotomy was performed, revealing haemorrhagic fluid in the peritoneal cavity and a substantial length of the necrotic small bowel. On further examination, a portion of the small bowel mesentery was found to be tethered beneath the mesh anchoring the vaginal vault to the sacrum. The mesh was divided, and 2 m of the necrotic bowel were resected. The residual mesh was excised and a primary small bowel anastomosis was performed.

Outcome and follow-up

Post-operatively, the patient was transferred to the intensive care unit and made a slow but uncomplicated recovery. She was discharged home on the 13th postoperative day, and has remained well since discharge.

Discussion

Sacrocolpopexy is an efficacious and widely used technique for the management of symptomatic vaginal vault prolapse.¹ Although the overall complication rate for the procedure is low, a range of gastrointestinal complications following the procedure have been previously described, including small bowel obstruction requiring laparotomy in the early postoperative period.² However, to our knowledge, this is the first report of delayed small bowel ischaemia as a direct result of synthetic mesh insertion at sacrocolpopexy. Closure of the peritoneum over the mesh to achieve ‘retroperitonealisation’, which has previously been advocated as a means of avoiding contact between the small bowel and the prosthesis,³ may have prevented this life-threatening complication. In this case, prompt recognition and early surgical intervention for small bowel ischaemia led to a favourable outcome.

Learning points.

• Life-threatening small bowel ischaemia can occur as a result of sacrocolpopexy mesh insertion, even several years after the procedure.

• Early recognition of an ischaemic bowel is essential, and a high index of suspicion is required, as signs of peritonism are often absent.

• Prompt operative intervention in patients with ischaemic bowel can result in a favourable outcome, even in an unstable patient with a profound lactic acidosis.