There has been a lot of coverage in the media in recent months over the use of mesh in surgical procedures. Much of this coverage has referred specifically to the use of transvaginal meshes for the treatment of rectocoele and transvaginal tapes placed by gynaecologists. In June 2014, the Scottish Health secretary announced a ban on these implants in Scotland.
We are often asked about meshes used in our surgery, most notably laparoscopic ventral rectopexy. This is very different surgery to that referred to by the Scottish Health Secretary. The mesh is placed by keyhole surgery into the abdomen in a sterile way, rather than through the vagina/ perineum (area around the bottom) which means infection is much less likely.
We have seen mesh problems after rectopexy and there have been reports from other centres. We have led an international study looking at how frequently the problem is seen and whether there are common features of patients who have experienced problems. This information has been presented at international meetings and is published (Evans, C. et al, Diseases of the Colon and Rectum: August 2015, Volume 58, Issue 8:p799–807)
Overall about two to three patients out of every hundred seem to have a problem with mesh after rectopexy. It may sometimes start out as a stitch problem that then progresses to involve the mesh as well. The mesh or stitch may work its way into the vagina and other times out into the bowel. Patients with this may experience bloody discharge with pus and pain from either vagina or rectum.
Surgery to deal with this problem may be straightforward and be done through the vagina or rectum. At other times, it may need a bigger operation done through the tummy either by keyhole surgery or with a bigger cut. This may be difficult surgery and occasionally may result in the need for a colostomy.
Patients may reasonably ask why mesh is used at all. Mesh is used very widely in surgery to help the body’s own tissues to heal up properly and to reduce the risk of prolapses and hernias coming back. Indeed the standard operation to fix a groin hernia (one of the most common of all operations) uses a mesh. Not to use mesh, therefore, increases the risk of symptoms and problems coming back, with the operation potentially more difficult to cure with each subsequent procedure.
The National Pelvic Floor Society recently issued guidance to its members on the use of mesh. It supported the continued use of mesh for rectopexy but made a number of recommendations. These included the need for surgeons to be appropriately trained, for the hospital to have a regular multidisciplinary team meeting (MDT) and for regular audit and data collection. All these are already features of our practice. Since the problem of mesh erosion has come to light, we have discussed this with our patients when weighing up the treatment options. We will be contributing to the planned national Society database on mesh implantation in order to monitor this problem.
In the meantime, we believe that the benefits of using mesh outweigh the risks. We will continue to monitor the situation closely. We now use only absorbable sutures for our rectopexies in an effort to minimize the risk of mesh infection and erosion. It is possible that ‘bio-mesh’ - biological meshes made from animal tissue - cause mesh problems less often than synthetic meshes, though there is as yet no clear evidence of this. Further data are awaited.
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