Migration of a mesh into the colon after inguinal hernia repair – a case report

Overview

Introduction: Mesh migration is one of the least common complications that arise after inguinal hernia repair with a mesh. Only small case series have been reported, and an understanding of this issue is limited due to a lack of data. Most of the cases were treated surgically. In this paper, we wish to present the potential of treating this condition using endoscopic techniques.

Case report: A male patient underwent transabdominal preperitoneal repair of a primary inguinal hernia in 1999. In 2003, the patient required the same procedure for a recurrent inguinal hernia. Twenty years after the primary hernia repair, the patient had a positive faecal occult blood test but was completely asymptomatic. A colonoscopy revealed mesh migration into the sigmoid colon. Despite multiple attempts to remove the mesh endoscopically, endoscopic treatment was unsuccessful. The migrated mesh was surgically removed and obligatory resection of the sigmoid colon was carried out. Apart from wound infection (Clavien-Dindo IIIb), the postoperative course was uneventful.

Conclusion: In our case, the mesh that had penetrated the colon could not be removed endoscopically. Despite our experience, it is advisable to attempt endoscopic removal of mesh that has migrated into a hollow intra-abdominal viscus.

Keywords:

inguinal hernia repair – complications – laparoscopy – mesh migration

Introduction

A tension-free hernia repair with a mesh is the recommended treatment method for symptomatic inguinal hernias in adult male patients [1]. The probability of developing an inguinal hernia over a lifetime is 27% for men and 3% for women [2]. Approximately 3% of inguinal hernias become incarcerated each year [1]. About 20 million inguinal hernia repairs are performed every year worldwide [3].  A number of potential complications that may result from an inguinal hernia repair with a mesh include seroma, haematoma, infection, chronic pain, ischemic orchitis, inguinal and genito­femoral hypesthesia, and urinary retention. [4,5]. Migration of the mesh is a less frequent complication. The term mesh migration is distinguished from the term mesh erosion by some authors [6]. Mesh migration is understood as a dislocation of the entire mesh into an organ. Mesh erosion, however, is understood to be a partial dislocation of the mesh through perforation into an organ [6,7]. Mesh migration has been reported in the urinary bladder, colon, scrotum, etc. [1,8−12]. In most cases, an open surgical procedure involving complete extraction of the mesh is necessary [6,13]. It is unclear what therapeutic potential a colonoscopy can provide in this complication. Although open surgery is usually inevitable, a colonoscopy alone has been successful in removing a mesh that has migrated into the colon in several cases [6,13]. We present our experience herein.

Case Report

A middle-aged man underwent a transabdominal preperitoneal (TAPP) repair of a left-sided inguinal hernia in 1999. The hernia recurred in the course of the next two years. The patient underwent a bilateral TAPP due to a recurrent left-sided and primary right-sided inguinal hernia in 2004. The identified cause of the recurrence was dislocation and folding of the cranial portion of the former mesh. The redo procedure was performed with non-adhesive composite mesh. The new mesh was fixed to the pubic bone and abdominal wall with titanium helical tacks. The former mesh was left in situ. The operation and postoperative course were uneventful. In the years following this procedure, the patient did not experience any adverse effects of the inguinal reoperation. In 2019, the colorectal cancer screening program revealed a positive faecal occult blood test. The patient was asymptomatic, with neither abdominal pain nor signs of hernia recurrence. A subsequent colonoscopy revealed a foreign body of unknown origin approximately 40 cm distatnt from the anal verge. Two experienced endoscopists repeatedly attempted to remove it with a snare but were unsuccessful (Fig. 1). Subsequently, an abdominal X-ray (Fig. 2) and a computed tomography scan (Fig. 3) shed light on the aetiology of the foreign body. It was a migrated mesh that had eroded into the sigmoid colon. The patient underwent open surgery with removal of the mesh and sigmoid colon resection (Fig. 4, 5). The inguinal region was obliterated due to post-inflammatory changes, which made an attempt at closer assessment of the inguinal region impossible. The dimensions of the extracted mesh were approximately 16×4.5×3 cm, and it was covered with haematoma. There were multiple small ulcer-like lesions on the mucosa of the sigmoid colon (Fig. 6). The patient eventually developed a surgical site infection. The wound was closed following two cycles of negative pressure wound therapy. The patient was discharged on postoperative day 13. There was no sign of a recurring inguinal hernia, which made us believe that the migrated mesh was the former one.

Discussion

In the case presented, the patient underwent three laparoscopic TAPP procedures: (i) a primary left-sided; (ii) a primary right-sided; and (iii) a redo of a left-sided TAPP repair. Today, a recurrent hernia would most likely be treated using a different approach. According to the European Hernia Society, a recurrent hernia that has undergone open repair should be treated with a la­paro-endoscopic approach, and conversely, a recurrent hernia that has undergone primary laparo-endoscopic repair should be treated by an open procedure (level of evidence 1b) [1,14,15]. There is, however, an exception to this rule. Repeated laparoscopic treatment of a recu­rrent hernia may be a reasonable option with a highly skilled surgeon experience (level of evidence 5) [15,16]. Primary bilateral inguinal hernia should be treated endoscopically (level of evidence 1b) [17,18].

The mean time interval between hernia repair and clinical manifestation of a migrated mesh is reported to be 59 months [13]. In our case, this time interval is unknown. The migration of the mesh was diagnosed 20 years after the primary hernia repair. Mesh migration has been reported after various mesh repairs. Most frequently, it is described following plug-and-patch repairs [1,19−21]. The clinical manifestation of a migrated mesh depends on its localisation. When the mesh migrates into the colon, the manifestation may very closely mimic a colorectal malignancy [22]. Manifestation varies from being completely asymptomatic to symptoms such as diarrhoea, haematochezia, the formation of an abdominal mass, weight loss, anorexia, and a colo-cutaneous fistula [13]. In the case presented here, the patient was asymptomatic. The only pathology that warranted a colonoscopy was the positive faecal occult blood test. It is a matter of debate whether this particular asymptomatic patient could have been treated with watchful waiting. Potential complications associated with mesh migration and colon perforation can be severe and may include mechanical ileus, intraabdominal abscess/peritonitis, necrotising fasciitis, and bleeding. [6,23]. Considering the size of the mesh extracted in our case (approximately 16×4.5×2.5 cm), there was considerable potential for the development of an obstructive ileus. In the long term, chronic inflammation of the colonic wall may introduce a culprit lesion for carcinogenesis [24].

According to a meta-analysis on mesh migration by Cunningham et al. (2019), the majority of 83 cases were treated surgically (91%), with 5 cases (6%) being treated conservatively and 2 cases (3%) endoscopically/cystoscopically [6]. In the cohort of surgically treated patients, it was necessary to perform an organ resection in 79% of cases [6]. Endoscopic treatment alone was successful in the removal of a migrated mesh only on an anecdotal basis [13]. In one particular case, the mesh migrated into the colon and passed through the anus spontaneously (Simons M. P., 2019, personal communication).

In order to prevent mesh migration after inguinal hernia repair, some authors believe that several technical details have to be addressed, i.e., choice of pro­per size and tailoring of the mesh, preference of light material, attention to detail in placement and fixation of the mesh, adequate coverage of the hernia defect, as well as precise closure of any defect in the peritoneum [25−27]. There are modifiable and non-modifiable factors impacting recurrence rate after inguinal hernia repair [27]. Patient risk factors are female gender, BMI of ≥30, smoking, diabetes mellitus, use of steroids, etc. [27] Surgical risk factors are preservation of cord lipoma, medial location of the defect, post­operative complication such as infection, and surgeon’s inexperience (annual inguinal herniorrhaphy volume of <5 cases and limited surgical experience) [17,27]. There are discordant data about the optimal type of mesh. Although The HerniaSurge Group has recommended using monofilament synthetic flat mesh with large pores (1–1.5 mm) with a bursting strength of 16 N/cm² [17], the meta-analysis of 6 randomised-controlled trials comparing heavy and light weight mesh did not find any statistical difference in recurrence rate of the studied groups [28]. On top of that, in contradiction to many studies, a Swedish follow-up study of >15 years encompassing 17 348 patients observed a significantly higher recurrence rate in patients with lower weight mesh than with heavy weight polypropylene mesh [29]. No difference in recurrence rate was observed in the subgroup analysis of TAPP and totally-extraperitoneal approach in the study by Curie et al. [28].

There are various methods of fixation of a mesh including tacks, staples, glues, sutures, fibrin sealants, and self-gripping mesh. According to International guidelines for groin hernia management, non-fixation of mesh is recommended in almost all hernia types in TEP and TAPP inguinal/femoral hernia repairs except large medial defects. In large medial defects, fixation and an adequate size and overlap  of the defect by mesh is recommended. Also, the reduction of dead space caused by the dilated transverse fascia is of importance [17].

Conclusion

Herein we report a case of mesh migration into the sigmoid colon that occurred following a laparoscopic inguinal hernia repair. The patient was treated with a colon resection. Due to the high number of hernia repairs performed worldwide every year, such scenarios will most likely become more frequent in the future. Although the majority of such cases are managed operatively, the treating physician must be aware that a number of patients can be successfully treated using endoscopic/cystoscopic or conservative method.

Abbreviations:

TAPP – transabdominal preperitoneal repair

Statements

Acknowledgement

The authors would like to acknowledge to Dr. Maarten P. Simons for his input on the preferable management of this patient.

Statement of Ethics

This paper complies with the guidelines for human studies and all procedures were conducted ethically and in accordance with the World Medical Association Declaration of Helsinki. Ethics approval was not required for the writing of this manuscript.

Ethical review board approval

Not required

Conflict of interests

The authors declare that they have not conflict of interest in connection with this paper and that the article has not been published in any other journal, except congress abstracts and clinical guidelines.

Author Contributions

J. K. and R. N. wrote the manuscript. M. Ky. operated on the patient and provided the images. M. Ko. evaluated the histological section of the endoluminal lesion. J. F. supervised the writing of the manuscript.

Jiri Fronek, MD, PhD,

Department of Transplantation Surgery,

Institute for Clinical and Experimental Medicine

Videnska 1958/9

140 21 Prague

e-mail: jiri.fronek@ikem.cz

ORCID: 0000-0003-2379-3886