Early sigmoid perforation involving left inguinal hernia mesh repair: a case report

Abstract

Injury to the underlying bowel is a serious potential complication following inguinal hernia mesh repair. Here the authors describe a rare case of a 69-year-old gentleman who initially presented with a deep collection in the retroperitoneum, which extended into the extraperitoneal space on the anterior abdominal wall 3 weeks following left inguinal hernioplasty. Early sigmoid perforation involving the inguinal hernia mesh repair was diagnosed, and he underwent a successful Hartmann’s procedure with mesh removal.

Highlights

• Complication of mesh repair treated initially with multiple interventional radiology-guided drainage.

• Failed conservative measures leading to surgical intervention.

Introduction

Mesh complications following a hernia repair have reduced over the years, especially after the advent of technology and improved surgical techniques and practice. Despite that, we do see them come through our hospital doors. Food and Drug Administration had analysed the reports and peer-reviewed literature, which suggested pain, infection, recurrence, adhesions and bowel obstruction as some of the common adverse events.

The importance of our case report lies in its complex nature and the decision to treat minimally invasively initially before eventually coming to a decision to intervene and operate.

This case will guide surgeons to have a low index of suspicion to taking patients to the theatre who have had no significant improvement with conservative management.

Case history

A 69-year-old gentleman with a background of gout, irritable bowel syndrome, varicose veins, left inguinal hernia repair (1993) and right inguinal hernia repair (1998) developed a recurrence of his left inguinal hernia, for which he underwent a transabdominal preperitoneal hernia repair with mesh in April 2019. Thirteen days postoperatively, he presented to the hospital with appetite loss, bleeding per rectum, and nausea. Computed tomography (CT) scan showed a large left infected collection in the retroperitoneum and extending into the extraperitoneal space on the anterior abdominal wall (Figs 1, 2). He was started on intravenous co-amoxiclav, and the next day he underwent ultrasound-guided drainage, with 150 ml drained. After 24 hours, the drain output was minimal and a repeat CT scan showed a kink in the drain, which required replacement under ultrasound guidance. He remained stable on the ward with gas and fluid continuing to drain. The patient made an informed decision at this stage for conservative management.

Figure 1.

Left-sided large infected collection with air locules (arrow).

Figure 2.

Large left-sided collection with air locules (arrow).

On day 11 of his admission, the drain again produced little output and a CT scan showed improvement in the appearance of the deep collection; however, there was a new subcutaneous extraperitoneal collection overlying the left femoral vessels. On day 15 of his admission, under CT guidance, the deep drain was withdrawn 8 cm and a further 40 ml was aspirated, completely draining the collection on the left pelvic side wall. The CT scan also showed that the superficial collection of air and faecal material extending into the left inguinal region was considerably smaller than on the previous CT scan 4 days prior. This collection communicated with the colon at the junction of the descending and sigmoid colon through a 1 cm hole in the cranial aspect of the mesh. The left mesh repair was noted, and metal clips were sited close to the colonic perforation. The femoral vessels were clear; the inferior epigastric vessels were close to the mesh, and the iliac vessels were well clear of the affected area. There were also inflammatory changes on top of the femoral vessels, but they were away from the area of concern.

After considerable discussion, the decision was made to intervene surgically on the 17th day of admission (31 days after the initial hernia repair). He underwent a lower midline laparotomy performed by a consultant general surgeon; during the procedure, the sigmoid colon was found attached to peritoneal closure, with a hole in the sigmoid at this point. There were faeces in the preperitoneal space with the drain. The sigmoid colon was taken off the left side wall, the peritoneum was closed, and contamination was controlled. The left colon was then mobilised, and the new mesh was mobilised off the iliac vessels and removed. The cavity was washed out and scrubbed, and the external opening was excised with the internal peritoneal defect closed around a drain. The omentum was then mobilised and used to plug the left internal peritoneal defect of the inguinal area. A lower left drain was placed in the pelvis and a left drain was placed in the preperitoneal space. The old mesh was identified as peritonealised and therefore not removed. Two corrugated drains were placed through the external old drain site, with one of these extending through the anterior abdominal wall defected into preperitoneal space. Finally, the sigmoid defect was brought out as a loop-defunctioning stoma.

Discharge planning began 14 days after the surgery, but with continuing purulent output in the remaining drain, a further CT was done 18 days postoperative, which showed a tiny collection/phlegmon in the left pericolic gutter but no drainable collection. The drain was withdrawn ∼1 in under local anaesthetic and secured in place with a suture. The patient was discharged from the hospital 20 days after the surgery.

Four months following the loop colostomy formation, he was seen in the clinic to discuss the reversal. A water-soluble contrast enema showed a normal calibre rectum and sigmoid colon with no evidence of stenosis or leak (Fig. 3). He has since undergone a reversal of his loop colostomy and will be reviewed in a clinic in 6 months’ time. He remains asymptomatic with his inguinal repair.

Figure 3.

Enema study showing patent anastomosis prior to reversal.

This case describes a rare presentation of colonic perforation following an endoscopic mesh repair. The work has been reported in line with the Surgical CAse REport (SCARE) criteria1.

Discussion

In the late 1890s, Theodor Brillah was the pioneer surgeon suggesting that the most effective approach for hernia repair is to use a prosthetic material to enforce the hernia wall defect2. In the early 1900s a variety of materials were used, but they all failed mainly due to infection, recurrence of hernia and rejections. Francis Usher studied different materials and their combinations to solve the problem and later introduced the polypropylene mesh; since then, the use of mesh has been popularised for hernia repair3.

The use of mesh has significantly reduced the recurrence rate following hernia repair; however, it is also known to have adverse effects. The early recognised complications include increased risk of infection4, haematoma and seroma formation, and later complications include abscess and enterocutaneous fistula formation5, mesh erosion and migration into visceral structures6. Most of these adverse effects are related to the structural and chemical properties of the mesh itself7.

Mesh erosion is known as a rare late complication following hernia repair, and the most common site of erosion is into the bladder8. However, this case demonstrates mesh erosion into the sigmoid colon approximately 2 weeks after the surgery.

Worth noting how the technique may affect migration rates by altering the tensile strength and degree of movement of the mesh. The nature of the biomaterial used is vital, as it impacts the degree of interaction with the adjacent tissue. The size, shape and positioning of the mesh also matter. Biologic agents are being used with increasing frequency in abdominal wall hernias, where they have been shown to decrease foreign body reactions and potential infectious complications9.

Conclusion

This report describes a rare colonic perforation involving mesh, and the case was complicated for several reasons: the timing of the perforation, the existence of a compromised mesh and the risk of being unable to remove it all safely. As the patient was septic and the source of infection was not controlled, surgical intervention was sought, and he successfully underwent a Hartmann’s procedure with mesh removal.

Usher was the pioneer surgeon to demonstrate a significant reduction in hernia recurrence following hernia repair using a nonresorbable mesh3. The use of mesh has significantly reduced the recurrence rate following hernia repair. However, they are known to be associated with early complications such as increased risk of infection4, haematoma, seroma formation and later complications including abscess and enterocutaneous fistula formation5, mesh erosion and migration into visceral structures.

Our case demonstrates mesh erosion into the sigmoid colon approximately 2 weeks after the surgery, although mesh erosion is commonly known as a late complication. Mesh migration following hernioplasty is an extremely rare complication; however, the most common site of erosion is the bladder8 in comparison to the sigmoid colon. In the literature, some of these rare complications have been described, such as small bowel obstruction secondary to mesh erosion and mesh migration into the colon10.

Ethical approval

Patient ethical approval given to authors.

Patient consent

Written informed consent was obtained from the patient for the 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.

Sources of funding

No funding for this research.

Author contribution

P.N. and F.S. are joint first authors who contributed to this report write up and collating data, study concept, data analysis and collection of images. Z.S. contributed to this report’s writing.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

None.

Guarantor

F. Salimi.

Provenance and peer review

Not commissioned, externally peer-reviewed.