What specialist should a patient with exposed abdominal mesh through the belly button be referred to?

Exposed Abdominal Mesh Through Belly Button: Specialist Referral

A patient with exposed abdominal mesh through the belly button should be urgently referred to a general surgeon experienced in hernia repair or a bariatric surgeon if the mesh was placed during bariatric surgery. 1

Rationale for Specialist Selection

Primary Referral: General Surgeon

• Exposed mesh represents a potential surgical emergency that requires evaluation by a surgeon with expertise in complex hernia management
• General surgeons are trained in the management of mesh complications including exposure, infection, and erosion
• The World Journal of Emergency Surgery guidelines recommend surgical intervention for complicated hernias, particularly when there are signs of mesh failure such as exposure 1

Alternative Referral: Bariatric Surgeon

• If the mesh was originally placed during bariatric surgery, a bariatric surgeon may be the most appropriate specialist 2
• Bariatric surgeons have specific expertise in managing complications related to bariatric procedures, including mesh-related issues
• The OBA guidelines emphasize that bariatric surgical complications should be evaluated by surgeons familiar with the altered anatomy resulting from these procedures 2

Clinical Significance of Exposed Mesh

Exposed mesh through the belly button represents a serious complication that requires prompt attention due to several risks:

• Potential for infection that could spread to surrounding tissues
• Risk of mesh erosion into adjacent organs if left untreated
• Possibility of enterocutaneous fistula formation 3
• Mesh failure characterized by shrinkage, detachment, and migration 3

Diagnostic Workup the Specialist Will Likely Perform

The surgeon will likely perform:

1. Detailed physical examination of the exposed mesh and surrounding area
2. CT scan with contrast enhancement - considered the gold standard for evaluating mesh complications with sensitivity of 14-82% and specificity of 87% 1
3. Possible endoscopic evaluation if there's concern about internal erosion 2

Treatment Options the Specialist May Consider

Treatment will depend on the extent of mesh exposure and associated complications:

1. Surgical removal of exposed mesh - Often necessary when mesh is infected or significantly exposed
2. Mesh revision - May be possible if exposure is limited
3. Complete hernia repair - May be required if mesh failure has occurred

The World Journal of Emergency Surgery guidelines recommend:

• For contaminated surgical fields, primary suture repair is preferred
• For clean fields, prosthetic mesh repair is the treatment of choice 1

Important Considerations

• Delay in appropriate referral increases risk of complications including infection and further mesh erosion
• Patients with cirrhosis and ascites have higher incidence of umbilical hernias (24%) and increased risk of complications 1
• Emergency surgery carries significantly higher complication rates (odds ratio 10.32) compared to elective procedures 1

Common Pitfalls to Avoid

• Referring to a non-surgical specialist - This is a surgical issue requiring surgical expertise
• Delaying referral - Exposed mesh should be considered an urgent surgical issue
• Attempting office-based management - This requires proper surgical evaluation and likely intervention in a surgical setting
• Failure to obtain appropriate imaging - CT scan is essential for proper evaluation of mesh complications 1, 3

By promptly referring to the appropriate surgical specialist, you can help ensure timely management of this potentially serious complication and reduce the risk of further mesh-related complications.