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CASE REPORTS
Year : 2021  |  Volume : 4  |  Issue : 4  |  Page : 228-230

Transrectal penetration of mesh after endoscopic inguinal hernia repair: An unusual delayed complication complication: A case report


Department of Surgery, King George’s Medical University, Chowk, Lucknow 226003, Uttar Pradesh, India

Date of Submission27-Mar-2021
Date of Decision14-May-2021
Date of Acceptance18-May-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Dr. Harvinder Singh Pahwa
Department of Surgery, King George’s Medical University, Chowk, Lucknow 226003, Uttar Pradesh.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_23_21

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  Abstract 

The majority of inguinal hernia repairs today, open or laparoscopic, are performed with mesh tension-free repair. The introduction of mesh, though beneficial, posed a new set of post-operative problems related with the mesh, and mesh migration or penetration is one of the most unusual ones with considerable morbidity. Mesh migration following laparoscopic repair is rare, and only a handful of cases have been reported in the literature. Here we present the first ever case report of mesh migration and penetration through rectum developing after two years post-operatively. The mesh was removed and the patient was discharged in a stable condition.

Keywords: Complication, endoscopy, hernia, inguinal, mesh


How to cite this article:
Pal AK, Pahwa HS, Kumar A, Singh KK. Transrectal penetration of mesh after endoscopic inguinal hernia repair: An unusual delayed complication complication: A case report. Int J Abdom Wall Hernia Surg 2021;4:228-30

How to cite this URL:
Pal AK, Pahwa HS, Kumar A, Singh KK. Transrectal penetration of mesh after endoscopic inguinal hernia repair: An unusual delayed complication complication: A case report. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Jan 20];4:228-30. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/228/334557




  Key Messages: Top


Mesh hernioplasty by endoscopic technique may have rare complications. This is the first ever case report of trans-rectal mesh penetration after total extraperitoneal (TEP) repair. We re-emphasize that the mesh must be implanted absolutely flat without any wrinkles close to the pelvic floor after adequate parietalization of hernial sac, and every effort should be made to identify and close any inadvertent peritoneal breach in TEP repair of inguinal hernia so as to avoid any mesh migration or penetration. Though the meticulous technique remains the established rule, some extremely rare complications may occur after TEP repair requiring astute awareness of surgeons.


  Introduction Top


It is well known that the inguinal hernia repair is one of the most commonly performed surgical procedures. Laparoscopy is a valid alternative to traditional open techniques for the treatment of hernia by the placement of mesh.[1] In the last two decades, this approach tends to become the gold standard procedure for the inguinal hernia. Late complication following laparoscopic approach is very low. We report the first ever case of mesh penetration through rectum as a delayed complication following totally extraperitoneal repair (TEP).


  Case History Top


A 60-year-old man with a body mass index of 28 kg/m2 presented with complaints of something coming out from anal opening for last 2 days along with vague lower abdominal discomfort. There was no recent history of vomiting, abdominal distension, fever, altered bowel habits, and abdominal trauma. The patient had undergone laparoscopic TEP repair of bilateral inguinal hernia 2 years back by using two meshes (one on each side) of size 15 × 12 cm polypropylene mesh (pore size of 164 × 96 µm and weight of 80-85 g/m2) along with non-absorbable spiral tack fixation and an uneventful post-operative period about 2 years back with an uneventful post-operative period. The patient had no other co-morbid medical or surgical illness. On examination, he was afebrile with stable hemodynamic parameters. A small non-tender bulge was present in the left iliac fossa and suprapubic region. Digital rectal examination revealed a foreign body (mesh) being felt about 5–6 cm from the anal verge. His laboratory parameters included normal total leucocyte count of 8,600 and mildly raised C-reactive protein level of 6.4 mg/L. His abdominal radiograph [Figure 1] showed multiple spiral-shaped radio-opaque shadows (non-absorbable tacks) in the region of rectum. Contrast-enhanced tomography was suggestive of well-defined hyperdensity noted in the rectum with mild circumferential thickening of rectal wall and perirectal fat plane stranding with few air specks noted within the right antero-lateral wall of the rectum near the intraluminal hyperdensity [Figure 2]. The mesh along with non-absorbable tacks was removed manually under spinal anesthesia [Figure 3]. Post-operative recovery was uneventful, and the patient was discharged on oral antibiotics and analgesics. Bulge in left iliac fossa subsided itself after 8 weeks and subsequent colonoscopy revealed normal anal canal, rectum, and colon with no evidence of ulcer or thickening and he underwent bilateral open hernioplasty (Lichtenstein repair). After 1 year of follow-up, the patient is presently not having any complaints.
Figure 1: Abdominal radiograph (arrow) showing multiple spiral-shaped radio-opaque shadows (non-absorbable tacks)

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Figure 2: Well-defined hyperdensity (arrow) noted in the rectum with few air specks within the right lateral wall of the rectum

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Figure 3: Mesh (arrow) extruding from anal verge and being removed

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  Discussion Top


Late complications related to mesh usage are rare. Mesh infection is one of them, with an estimated incidence of 0.1–0.2% after laparoscopic inguinal hernia repair.[2],[3],[4] Till date, very few cases of migration of mesh after endoscopic inguinal hernia repair have been reported so far and in three of them mesh migrated into the urinary bladder out of which two of them occurred in the transabdominal preperitoneal repair.[5],[6] Other cases included combined mesh infection with mesh migration following TEP repair,[7] and a single case reported mesh migration into small bowel, leading to obstruction.[8] In all of these cases, patients underwent laparotomy and mesh removal. Another study has investigated mesh migration and the position of the hip joint in TEP[9] and described the need for minimizing the strenuous activity and bending in the immediate post-operative period, during which mesh and staples have the greatest risk of dislodging.

In this case report, we propose that the mesh edges might have impinged upon the surface of rectosigmoid through some inadvertent peritoneal breach leading to chronic subclinical inflammation and subsequent penetration of mesh as the most likely explanation of sequence of events. As the patient did not have any abdominal complaints, his mesh removal through anal canal was uneventful with minimal post-operative morbidity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Neumayer L, Jonasson O, Fitzgibbons R, Henderson W, Gibbs J, Carrico CJ, et al. Tension-free inguinal hernia repair: The design of a trial to compare open and laparoscopic surgical techniques. J Am Coll Surg 2003;196:743-52.  Back to cited text no. 1
    
2.
Ramshaw B, Abiad F, Voeller G, Wilson R, Mason E. Polyester (parietex) mesh for total extraperitoneal laparoscopic inguinal hernia repair: Initial experience in the United States. Surg Endosc 2003;17:498-501.  Back to cited text no. 2
    
3.
Jalilvand A, Sarker S, Fisichella PM. A rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. Surg Laparosc Endosc Percutan Tech 2015;25:e69-71.  Back to cited text no. 3
    
4.
Yadav AK, Bindal V, Jangra VK, Khan Z, Ahangar S, Sharanappa V, et al. Delayed mesh infection: A rare complication of laparoscopic inguinal hernia repair (TEP—totally extra-peritoneal repair). Surg Sci2016;7:453-60.  Back to cited text no. 4
    
5.
Bodenbach M, Bschleipfer T, Stoschek M, Beckert R, Sparwasser C. Intravesical migration of polypropylene mesh implant 3 years after laparoscopic hernioplasty. Urolage A 2002;41:366-8.  Back to cited text no. 5
    
6.
Hume RH, Bour J. Mesh migration following laparoscopic inguinal hernia repair. J Laparoendosc Surg 1996;6:333-5.  Back to cited text no. 6
    
7.
Chowbey PK, Bagchi N, Goel A, Sharma A, Khullar R, Soni V, et al. Mesh migration into the bladder after TEP repair: A rare case report. Surg Laparosc Endosc Percutan Tech 2006;16:52-3.  Back to cited text no. 7
    
8.
Xue TM, Tao LD, Zhang J, Zhang PJ. Mesh erosion causes small bowel obstruction: A rare complication of laparoscopic inguinal hernia repair: Case description and review of literature. Hepatogastroenterology 2015;62:55-8.  Back to cited text no. 8
    
9.
Choy C, Shapiro K, Patel S, Graham A, Ferzli G. Investigating a possible cause of mesh migration during totally extraperitoneal (TEP) repair. Surg Endosc 2004;18:523-5.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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