Laparoscopic management of mesh erosion into small bowel and urinary bladder following total extra-peritoneal repair of inguinal hernia.

Mesh erosion into visceral organs is a rare complication following laparoscopic mesh repair for inguinal hernia with only 15 cases reported in English literature. We report the first case of complete laparoscopic management of mesh erosion into small bowel and urinary bladder. A 62-year-male underwent laparoscopic total extra-peritoneal repair of left inguinal hernia at another centre in April 2012. He presented to our centre 21 months later with persistent lower urinary tract infection (UTI). On evaluation mesh erosion into bowel and urinary bladder was suspected. At laparoscopy, a small bowel loop was adhered to the area of inflammation in the left lower abdomen. After adhesiolysis, mesh was seen to be eroding into small bowel. The entire infected mesh was pulled out from the pre-peritoneal space and urinary bladder wall using gentle traction. The involved small bowel segment was resected, and bowel continuity restored using endoscopic linear cutter. The resected bowel along with the mesh was extracted in a plastic bag. Intra-operative test for leak from urinary bladder was found to be negative. The patient recovered uneventfully and is doing well at 12 months follow-up with resolution of UTI. Laparoscopic approach to mesh erosion is feasible as the plane of mesh placement during laparoscopic hernia repair is closer to peritoneum than during open hernia repair.

INTRODUCTION

Laparoscopic repair is the gold standard treatment of inguinal hernia. It involves placement of mesh in pre-peritoneal space. However, mesh is a foreign body which can migrate as well as erode into surrounding visceral organs including urinary bladder and bowel. Such an occurrence is rare with only few cases been reported in English literature following laparoscopic mesh hernioplasty.[12345678910] We report the first case of complete laparoscopic management of mesh erosion into small bowel and urinary bladder in a patient who had undergone total extra-peritoneal repair (TEP) of left inguinal hernia earlier. We discuss the literature as well as the mechanisms of mesh migration and erosion.

CASE REPORT

A 62-year-male underwent laparoscopic TEP repair of left inguinal hernia in April 2012 at another centre. The peri-operative course was uneventful. Six months later he developed intermittent mild pain in left groin. The pain was managed conservatively with analgesics. Ten months after the surgery he reported symptoms of burning micturition, increased frequency, pyuria and persistent left groin pain. He was diagnosed to have lower urinary tract infection (UTI). Urine microscopy showed plenty of pus cells and culture grew Escherichia coli sensitive to multiple drugs. However, the patient did not respond to antibiotics and continued to grow E. coli with similar sensitivity pattern in subsequent urine cultures. He was referred to our institute for further management. An abdominal ultrasonography showed abscess at hernioplasty site in continuity with the thickened left antero-lateral bladder wall. Computed tomography (CT) scan revealed inflammatory changes in the left inguinal region with abscess, mural thickening of antero-lateral wall of urinary bladder, small air foci in urinary bladder and adherence of a thickened bowel loop to area of inflammation [Figure 1]. Flexible cystoscopy revealed a small polypoidal lesion with surrounding bullous oedema and inflammation in left antero-lateral bladder wall. Cystoscopic biopsy of the polypoidal lesion showed non-specific inflammatory lesion with cystitis.

Figure 1

Contrast-enhanced computed tomography scan showing thickening of antero-lateral wall of urinary bladder with air foci in urinary bladder and adherence of a thickened bowel loop to area of inflammation

Laparoscopic assessment was planned in view of suspected intra-peritoneal mesh migration. A three-way urinary catheter was inserted after the induction of general anaesthesia. At laparoscopy, omentum and small bowel were adhered to the left inguinal region. In addition, a bulge was seen in the region of left antero-lateral wall of urinary bladder [Figure 2]. During adhesiolysis of the bowel loop, it became apparent that the mesh was eroding into small bowel at one end and through the pre-peritoneal space into the bladder at another end. The entire mesh was pulled out into abdomen from pre-peritoneal space by applying gentle traction using graspers. The involved small bowel was resected using 60 mm endo GIA stapler (Echelon 60, Ethicon Endosurg Inc.). Bowel continuity was established with side to side anastomosis. The common enterotomy was closed with a continuous 2-0 Polydiaxonone. Pre-peritoneal space was thoroughly irrigated with saline. Bladder was filled with about 400 ml of methylene blue-saline to check for leak, which was absent. A suction drain was placed in the pelvis and left paracolic region. The resected small bowel segment along with eroded mesh [Figure 3] was retrieved in a custom made plastic bag.

Figure 2

Laparoscopic view of left inguinal region showing adhered small bowel along with a bulge in wall of urinary bladder

Figure 3

Resected bowel with the eroded mesh

Post-operative course was uneventful. The patient was started orally on 3rd post-operative day. The drain was removed on 4th post-operative day. The patient was discharged with urinary catheter in situ, which was subsequently removed 2 weeks later in the outpatient clinic. Oral nitrofurantoin was continued for 6 weeks. At 12 months of follow-up, patient is symptom-free, and urine culture is sterile. Interestingly, the hernia has not recurred.

DISCUSSION

Laparoscopic inguinal hernia repair is a safe procedure with low rate of complications. These include trocar site bleeding, injury to urinary bladder and bowel, mesh migration and erosion. Mesh erosion into bowel and/or urinary bladder following laparoscopic inguinal hernia repair is a rare complication. In English literature, only 15 cases of mesh erosion following laparoscopic inguinal hernia repair have been reported. Erosion has been reported in urinary bladder in nine cases, in colon in four cases and both colon and bladder in remaining two cases. The latter resulted in colovesical fistula. Majority of the cases have occurred following trans-abdominal pre-peritoneal (TAPP) repair. The interval between hernia repair and presentation ranged from 6 months to 16 years. The mode of presentation and their management has been summarised in Table 1. In cases involving urinary bladder, recurrent UTI was the most common presentation. In some cases mesh acted as the nidus for a calculus.[689] All cases except two required open approach with partial cystectomy in majority. These two cases could be managed cystoscopically.[46]

Table 1

Some published reports of mesh erosion following laparoscopic inguinal hernioplasty

In one case involving bladder and bowel, no intervention was required for the bladder.[10] Similarly, in present case in which the mesh was eroding into both bowel and bladder, we did not require any intervention for the bladder except for leaving the urinary catheter for 2 weeks. It is well-known that erosion is a slow process leading to dense adhesions and fibrosis in the surrounding region. This may explain the absence of leak from the bladder. Management of colonic erosion generally requires laparotomy with resection of the involved bowel or colonoscopic removal ion case of complete erosion.

Mesh erosion/migration should be suspected in a patient presenting with regional pain, urinary or bowel symptoms after a laparoscopic inguinal hernia repair. Evaluation of the patient should include sonography, CT and if required, cystoscopy. A complete evaluation will aid in better operative planning. Ultrasonography is generally the initial investigation. In the presence of collection or inflammation, a contrast-enhanced CT scan is indicated. CT would define involved organs and extent of disease such as perforation, fistulae, and abscess. CT sinogram is preferred in the presence of sinus. Cystoscopy is indicated in cases with bladder involvement, where it can be diagnostic and even therapeutic.[4]

Peritoneal damage and infection of the mesh are important factors leading to mesh erosion. A peritoneal defect leads to direct contact between mesh and intra-abdominal organs resulting in adhesions, mechanical bowel obstruction, and fistula formation. This may also explain the higher number of cases being reported after TAPP than TEP. Agrawal and Avill[4] have postulated that primary mesh migration occurs along the paths of low resistance either due to inadequate fixation or external displacing forces. Failure to fix the mesh may result in mesh displacement although fixation increases possibility of adhesions and nerve injury. Similarly, strenuous activity including bending and hip flexion in the immediate post-operative period (during which mesh and staples have the greatest likelihood of dislodging) may be a causative factor. On the other hand, secondary migration occurs as a consequence of foreign body reaction leading to erosion through the anatomic planes. Weakening of wall and erosion of viscus can also occur due to sharp cut edges of mesh leading to inflammatory reaction.[5]

CONCLUSION

Mesh erosion/migration should be suspected in any patient presenting with regional pain, urinary or bowel symptoms following laparoscopic mesh hernia repair in the past. Laparoscopic approach is feasible in such patients as plane of placement of mesh is closer to visceral organs. Further, it gives an opportunity to assess the extent and nature of involvement of organs and in the presence of expertise, successful surgical management can be accomplished using minimally invasive approach.