Surgeons should use caution when anchoring mesh to the diaphragm, following 15 cases of cardiac tamponade caused by the procedure, including eight deaths.

Researchers at the Chicago Institute of Minimally Invasive Surgery (Skokie, IL, USA) conducted a search of the US Food and Drug Administration (FDA) manufacturer and user device experience (MAUDE) database and the PubMed Medline database to identify 15 distinct cases of cardiac injury during hernia repair using mesh anchored to the diaphragm. Ten of these were during hiatal hernia repair, resulting in six deaths, and five in ventral hernia repair, four of which were fatal. The researchers also reported on two previously unpublished cases.

The study revealed that the most common cause of injury was helical tacks, accounting for 10 of the 15 injuries; two further injuries were caused by sutures, one by a straight stapler, and the rest from unknown causes. Helical tacks, made from titanium wire about 4 mm long, are often delivered in the tissue blindly and, after thinning the tissue, are deployed completely before ejecting the tack. Thus, the tack is advanced into the tissue with the leading edge penetrating beyond visualization; If the tack is fired into tissue less than a minimum of 4 mm thick, injury to an underlying organ, such as the pericardium, heart, or intestines is possible. The study was published ahead of print on September 25, 2011, in Surgery.

“Anchoring mesh to the diaphragm is not to be taken lightly, regardless of the type of mesh being used. The careless placement of sutures, staples, and especially the helical tacker may result in a catastrophic injury to the heart,” concluded study authors Constantine Frantzides, MD, PhD, and Scott Welle, DO. “Only with appropriate awareness and recognition can this catastrophic complication be avoided.”

Cardiac tamponade is a compression of the heart that occurs when blood or fluid builds up in the space between the myocardium and the pericardium. This prevents the ventricles from expanding fully, and the excess pressure from the fluid prevents the heart from functioning normally. The initial symptoms of tamponade, which include tachycardia and hypotension, can be mistaken for more common complications, such as pulmonary embolism (PE), heart failure, and myocardial infarction (MI). The authors also noted that clinical manifestation of tamponade could present at any time postoperatively, even as late as 14 days.
 

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