Mesh Erosion into Sigmoid Colon after Inguinal Hernia Repair.

To the Editor: Tension-free hernia repair with mesh is currently the most popular technique for herniorrhaphy. Although it is well tolerated with few complications, late-onset complications, such as mesh migration, erosion into associated structures, enterocutaneous fistula, and abscess formation, have been reported.[1] We herein report a case of a 67-year-old male with mesh erosion into the sigmoid colon after inguinal hernia repair.

A 67-year-old male, who underwent laparoscopic tension-free herniorrhaphy via transabdominal preperitoneal approach four years ago, was admitted because of a 2-month history of increasing severe lower abdominal pain. The pain was not related to diet, and the patient did not experience nausea, vomiting, hematochezia, diarrhea, or emaciation. Abdominal computed tomography scan revealed circumferential wall thickening of sigmoid colon adherent to the bladder presenting as a suspected colonic malignancy. A mesh plug was found involving the sigmoid colon by colonoscopic examination [Figure 1]. Laparoscopic sigmoid resection was performed with primary end-to-end reanastomosis using the 31 EEA stapling device (Reach Surgical, TianJin, China). Ten centimeters of the sigmoid colon containing the mesh was removed. The patient had an unremarkable postoperative course and was discharged on the 7th postoperative day.

Figure 1

Colonoscopy showing a mesh in the sigmoid colon.

Recurrence is the most common complication for inguinal hernia repair, even with mesh. Complications unique to mesh repair have been reported, such as inguinodynia. More serious complications include contraction, migration, and erosion into the adjacent organs. However, mesh migration is unusual and primarily erodes into the urinary bladder. Bowel complications are more infrequent and grievous. There are rare isolated reports of complications for migrated mesh eroding into the colon.

The exact etiology of the complication encountered in our patient remains unclear. During the initial surgery, the mesh should be sutured to the abdominal wall, and then the peritoneum can be reconstructed with a continuous suture to cover the mesh plug. When both of these sutures are insecure, the mesh would migrate into the peritoneal cavity and erode into the sigmoid colon. Al-Subaie et al.[2] presumed that the pressure necrosis resulting from the physical contact between the mesh and the colon lead to fistula formation and consequently to mesh migration into the colon. D’Amore et al.[3] found that 5 of 7 patients (2 involving cecum and 5 involving left colonic after plug repair) suffered from diverticular disease and thought that diverticular inflammation might induce the plug to erode into the colon.

What can we do to avoid this complication? Moorman and Price[4] believed that lack of fixation of mesh predisposes to its migration. D’Amore et al.[3] considered that other technical details, such as to avoid the excision of the sac, identify and repair any hole in the peritoneal sac, use pre-shaped devices, and choose the proper size and light material, could reduce the incidence of this complication. Regardless of the type of mesh repair (open or laparoscopic), meticulous care for correct placement and reliable suture is necessary to avoid complications. Suturing the mesh to the surrounding fascia is a critical step during the operation.

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Conflicts of interest

There are no conflicts of interest.