Abstract
Introduction and importance
Repairing incisional abdominal wall hernia with nonabsorbable meshes is one of the most common procedures in general surgery. Mesh migration into the intestine is rare but a serious complication. It can occur months or even years after surgery and often presents with vague abdominal pain, making diagnosis tricky.
Case presentation
We report a rare case of a 52-year-old female presenting a small bowel obstruction secondary to mesh migration from the abdominal wall into the intestine, 10 years after repeated surgical repair of a ventral incisional hernia. At surgery, a mesh was migrated into a small bowl. The patient had a small bowel resection. The postoperative course was simple and the patient was discharged after 5 days.
Case discussion
Incisional hernia repair with mesh is one of the most commonly performed surgical procedures worldwide. Many complications have been linked to the use of mesh; among the most frequently reported are seromas, hematomas, and infections. Mesh migration remains an uncommon event after incisional hernia repair, and even rarer when considering complete migration within the intestinal lumen. The exact cause of this complication remains unknown. Multiple hypotheses have been proposed for mesh migration. Abdominal pain, intermittent or persistent intestinal obstruction, mass formation, and viscus perforation represent the most common clinical manifestation. Total removal of the mesh via laparoscopy or laparotomy is recommended, along with either partial or entire resection of the organ.
Conclusion
Mesh migration is a an uncommon possible complication in case of incisional hernia mesh repair and it requires often surgical intervention.
Keywords: Incisional hernia; Repair,mesh; Migration; Intestine; Case report
Highlights
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Mesh migration post-incisional hernia repair is an uncommon complication.
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The occurrence of mesh migration into intraabdominal organ is exceptionally rare.
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Mesh migration symptoms vary depending on the affected organ.
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Mesh migration can lead to major complications necessitating surgery.
1. Introduction
Incisional hernia(IH) is among the most common complications of abdominal surgery. The occurrence of IH is estimated to be between 10 % and 15 %, with a recurrence rate ranging from 5 % to 20 % [1]. Mesh is commonly employed for abdominal hernia repair because it ensures a low recurrence rate. Mesh implantation, however, carries its risks and complications. Mesh migration of intra-abdominal organs is rare but a serious complication [2]. This complication can occur months or even years after surgery and often presents with vague abdominal pain, making diagnosis tricky [3]. We report a rare case of mesh migration to the small intestine causing intestinal obstruction. This case report was performed with the recent SCARE criteria [4].
2. Case presentation
The patient is a 52-year-old female with a past medical history of hypertension and diabetes. She underwent four previous abdominal surgeries, including three cesarean sections and a total hysterectomy through a midline incision. The patient presented a large incisional abdominal hernia, one year after her last surgery. She had a laparotomy sublay hernia repair with polypropylene mesh under since one year. Her postoperative course was uncomplicated. Roughly a decade post-incisional hernia repair, the patient presented to the emergency department reporting acute abdominal pain accompanied by episodes of nausea and vomiting. She had been experiencing this pain for the two years leading up to the presentation, and it had been progressively worsening. Her vital signs were within normal ranges. During the physical examination, her abdomen was observed to be mildly distended. Furthermore, a small reducible incisional hernia was palpable. All laboratory results were within normal limits. A computed tomography scan of the abdomen and pelvis was performed, it objectives circumferential wall thickening of the intestine adherent to the abdominal wall causing intestinal obstruction (Fig. 1). Median laparotomy was performed, including the site of primary repair. It was observed that the intestine was completely adhered to the anterior abdominal wall. Dissection between the fascia and the small bowel was performed to free the intestine, revealing a mesh that had eroded into the small bowel. Other intraabdominal organs appeared intact. Examination of the primary site of incisional hernia repair showed no residual mesh. Following this, the segment of the intestine attached to the mesh was removed en bloc with the mesh (Fig. 2). An anastomosis was created between the remaining sections of intestine. The abdominal wall defect was closed using primary closure. The postoperative recovery was uneventful, and the patient was discharged after five days.
Fig. 1.
Abdominal CT revealed circumferential wall thickening of a small bowl adherent to the abdominal wall.
Fig. 2.
The surgical specimen showed the eroded mesh prosthesis protruding into the intestine.
3. Discussion
The most common complication of abdominal surgery is an incisional hernia, which affects approximately 10–15 % of patients [1]. For larger incisional hernias (>4 cm), mesh repair is the preferred treatment due to its significantly lower risk of recurrence compared to other methods [5]. Many complications have been associated with mesh; the most commonly reported are seromas, hematomas and infection [6]. mesh migration remains an uncommon event after incisional hernia repair, and even rarer when considering complete migration within the intestinal lumen [7]. The exact cause of this complication remains unknown. Multiple hypotheses have been proposed for mesh migration. This complication was categorized by Agrawal et al. into primary and secondary types [8]. Primary mesh migration refers to the movement of a mesh due to insufficient fixation or external forces that encourage displacement. Secondary migration can occur across anatomical planes, driven by erosions initiated by the foreign body reaction [8]. Some technical details could increase the risk of mesh migration, such as identification and repair of any hole in the peritoneal sac, avoiding excision of the sac, proper fixation of the mesh, and choosing the proper mesh size and material [9]. The risk associated with mesh erosion and migration concerning various techniques used for mesh implantation in ventral hernia repair remains uncertain. Several literature reviews on mesh migration were published, but they only included a limited number of cases [10].Mesh migration is much higher if the mesh is placed intraperitoneally in direct contact with the viscera. Retro-rectus or preperitoneal mesh location was showed to be the best option with respect to both recurrence and surgical site infection when compared to the other types of mesh placement [11]. Some authors suggest that sutureless mesh implantation, by bypassing surgical mesh fixation, may elevate the risk of migration. However, this contention has been subject of debate [9,12]. Clinical presentations of mesh migration are variable and related to the organ involved. Abdominal pain, intermittent or persistent intestinal obstruction, mass formation, and viscus perforation represents the most common clinical manifestation [[13], [14], [15]]. Ultrasound can be beneficial in diagnosing mesh migration but limited in most cases. CT scan provide superior imaging of the mesh compared to ultrasound, but it is not always possible because many synthetic and biologic meshes are difficult to see on CT [16]. Total removal of the mesh via laparoscopy or laparotomy, along with either partial or entire resection of the organ, is recommended in case of mesh migration. Once the mesh is totally migrated into the intestine, bowel resection is usually required [17]. Our patient had bowel resection taking away the mesh. To mitigate the risk of infection following mesh removal, a staged operation with delayed placement of a new mesh is recommended [18]. This process may require six months to one year for completion [19]. Biologic mesh could be employed to address the parietal defect following bowel resection and can treat the hernia defect in a single operation [20]. Currently, there is a lack of evidence in the literature due to the limited number of direct comparisons. In our case, we chose to proceed with the staged operation.
4. Conclusion
Mesh migration to intestine is a very rare complication of incisional hernia repair with a prosthetic mesh. There is no clear cause of this complication. Clinical presentations are variable and non specific. The results of mesh migration are serious and require surgical intervention.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Ethical approval
All procedures performed in studies involving human participants were by the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical clearance was not necessary as the format of this paper is a case report.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author contribution
All the authors participated in the treatment of the patients, writing, and approving the manuscript.
Guarantor
Mohamed Ali Chaouch.
Research registration number
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Conflict of interest statement
No conflict of interest to disclose.
Acknowledgments
None.
References
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