Hernia (2010) 14:313–315
DOI 10.1007/s10029-009-0536-8
C A S E RE P O RT
Recurrent inguinal hernia due to mesh dissolution:
two case reports
M. Shamim
Received: 26 April 2009 / Accepted: 28 June 2009 / Published online: 28 July 2009
© Springer-Verlag 2009
Abstract The recurrence of inguinal or other abdominal
hernia due to Prolene polypropylene mesh dissolution has
never been reported in the literature. This is a report of two
cases of recurrent inguinal hernias after mesh hernioplasty,
but, on exploration, no mesh was found.
Keywords Prolene · Polypropylene mesh · Mesh
dissolution · Hernia recurrence · Inguinal hernia ·
Hernioplasty · Mesh repair
Introduction
The recurrence of inguinal hernia after mesh hernioplasty is
reported in 1–10% cases [1]. Reported causes include faulty
surgical technique, e.g. failure to secure the mesh medially,
too small a mesh, missed hernia and cord lipoma [2]. A
polypropylene (Prolene) mesh is long-lasting and never dis-
solves. If it does dissolve, it is certainly not original Prolene
mesh. The presence and distribution of counterfeit Prolene
mesh has been reported in the literature [3].
Case report 1
A 38-year-old male, on follow-up visit at 6 months, was
noted to have recurrence of right inguinal hernia. He was
operated 6 months previously (by the author) for uncompli-
M. Shamim (&)
Department of Surgery,
Fatima Hospital and Baqai Medical University,
Karachi 74600, Pakistan
e-mail: surgeon.shamim@gmail.com
cated complete right inguinal hernia, in which (Prolene)
mesh hernioplasty was done. The postoperative recovery
was uneventful and he had no history of predisposing fac-
tors. On examination, incisional scarring was present and
the hernia was reducible and complete.
On re-exploration, a shocking and surprising Wnding was
the absence of mesh; anchoring interrupted Prolene sutures
were in place. Following herniotomy, a double-repair was
performed incorporating Darning’s and Lichtenstein’s repair
in a single step. This was done by taking Prolene sutures
through both the inguinal ligament and Prolene mesh at the
same time, while performing Darning’s repair; the mesh was
then Wxed over the Darning’s repair, in the usual way with
interrupted Prolene sutures. The post-operative period was
uneventful. There was no recurrence at 3 years.
Case report 2
A 52-year-old male was admitted with the diagnosis of
recurrent left inguinal hernia. He was operated 3 years pre-
viously (by another surgeon in the same city) for uncompli-
cated left inguinal hernia, in which (Prolene) mesh
hernioplasty was done. The patient gave no history of pre-
disposing factors like prostatism, chronic cough, chronic
constipation, weight lifting, smoking and wound infection.
On examination, incisional scarring was present in left
groin. The hernia was reducible and incomplete.
After spinal anaesthesia, a left inguinal incision was
made by excising the previous scar. External oblique apo-
neurosis was opened. The cord and indirect hernial sac
were dissected out. The surprise Wnding was the absence of
any Prolene mesh over the posterior inguinal wall, though
anchoring interrupted Prolene sutures were in place
(Fig. 1). Following herniotomy, modiWed Lichtenstein’s
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Fig. 1 Posterior wall of the recurrent inguinal hernia showing Prolene
sutures (white arrows) but no mesh
repair (as above) was performed; the post-operative period
was uneventful.
Discussion
Inguinal hernia surgeries are among the most common gen-
eral surgical procedures. The surgical techniques and
implanted materials are crucial to the result of hernia repair.
Lichtenstein hernioplasty for the repair of primary inguinal
hernia has been well established and constitutes the current
gold standard [4]. However, the recurrence at 5 years still
varies between 1 and 10% [1, 5, 6]. Several modiWcations
of Lichtenstein’s repair have been made to reduce the
recurrence rate.
Amid [7] identiWed the following key principles of
Lichtenstein’s repair to avoid recurrence: (1) use of a large-
sized mesh that will extend approximately 2 cm medial to
the pubic tubercle, 3 to 4 cm above Hesselbach’s triangle
and 5 to 6 cm lateral to the internal ring; (2) cross the tails
of the mesh laterally to avoid recurrence lateral to the
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Hernia (2010) 14:313–315
internal ring; (3) secure the mesh with two interrupted
sutures on the upper edge and one continuous suture with
no more than three to four passes on the lower edge of the
mesh to prevent folding and movement of the mesh in the
groin; (4) position the mesh in a slightly relaxed dome-
shape conWguration to counteract the forward protrusion of
the transversalis fascia when the patient stands up from the
intraoperative supine position; (5) identify and protect the
ilioinguinal, iliohypogastric and genital nerves throughout
the operation.
The majority of recurrences after a Lichtenstein repair
were medial or suprapubic, due to insuYcient mesh medi-
ally [5, 6, 8, 9]. An unrecognised indirect hernia in patients
operated for a direct inguinal hernia can also cause recur-
rence [6]. Felix et al. had reported the following mecha-
nisms of recurrence: inadequate lateral Wxation of the mesh,
inadequate lateral Wxation compounded by too small a
mesh, missed lipoma of the cord, inadequate Wxation of the
mesh medially to Cooper’s ligament (mostly associated
with too small a mesh), a missed hernia and a hernia
through a keyhole in the mesh [2]. Garavello et al. found
mesh and/or plug dislocation as the most frequent cause of
recurrence, followed by a failure of the internal ring recon-
struction, loss of the pubic stitch and the use of a reabsorb-
able type mesh [10].
In this report, the cause of recurrence was the absorption
or dissolution of non-absorbable polypropylene (Prolene)
mesh. A counterfeit version of Ethicon’s Prolene (polypro-
pylene) mesh has been known to be distributed to USA hos-
pitals and used in patients undergoing tension-free hernia
repair. The Food and Drug Administration (FDA) had con-
Wrmed that the counterfeit mesh has the same physical char-
acteristics as the original Prolene mesh, but stated that it
was not sterile or safe to use [3]. The FDA statement is
given just to highlight the presence of counterfeit/pirated
mesh on the market. With such products, one can expect
any degree of adverse events. The situation in Pakistan is
even worst; the counterfeit/pirated mesh has caused not
only an increased number of cases with infection and
seroma formation, but also recurrences due to complete dis-
solution of the mesh. The mechanical properties of Prolene
in terms of absorbability has not been previously ques-
tioned or reported. However, biological mechanisms can
also be involved, possibly by the production of unknown
catalytic enzymes in some patients; this needs to be investi-
gated. A questionnaire has already been designed to gather
data about recurrences due to Prolene mesh dissolution,
from other surgeons of Pakistan and other regions of the
world; the results will be published in the near-future.
A gold standard technique for the repair of recurrent
inguinal hernia has not been established. Surgeons mostly
decide peri-operatively which procedure to use. A transin-
guinal approach with a minimal direct suture repair for
Hernia (2010) 14:313–315
small defects or a preperitoneal approach for inserting a
large mesh can be used [5]. Lichtenstein hernioplasty also
stands as a safe option for the repair of recurrent inguinal
hernias [4]. Due to large-size defects in both cases (men-
tioned above), a decision was made for Lichtenstein’s
repair, with a large-sized mesh (7.5 £ 15 cm); additionally,
because of doubt regarding original or counterfeit mesh, a
modiWcation was made incorporating Darning’s repair
underneath the Prolene mesh.
Conclusions
The implantation of counterfeit/pirated Prolene polypropyl-
ene mesh can lead to adverse events such as recurrences
(from complete dissolution/absorption). The surgeons deal-
ing with hernias should know the diVerence between origi-
nal and pirated Prolene mesh. Additional reinforcement of
the posterior wall of the inguinal canal can be done in cases
of doubt in order to avoid recurrence.
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