Avtar Pachauri1*, Harvinder Singh Pahwa1, Awanish Kumar1
1Department of General Surgery, King George Medical University, Lucknow, Uttar Pradesh, India
*Corresponding Author: Avtar Pachauri, Department of General Surgery, King George Medical University, Lucknow, Uttar Pradesh, India; Email: [email protected]
Published On: 08-01-2021
Copyright© 2020 by Pachauri A, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Majority of inguinal hernia repairs today, open or laparoscopic, are performed with mesh tension-free repair. The introduction of mesh, though beneficial, poses its own gamut of postoperative problems; mesh migration being the most unusual, increases morbidity and financial burden. Only a handful of cases of mesh migration have been reported in literature. Here we report the first case to our knowledge, of mesh migration through rectum developing 2 years postoperatively. The mesh was removed manually and the patient was managed conservatively and discharged. This case highlights the importance of recognising mesh migration as a complication of hernia repair and thus we suggest that all the cases of mesh migration should be reported and further research should be done to find out the cause of this occurrence and thereby taking necessary steps to prevent its incidence.
Keywords
Laparoscopic Hernia Repair; Mesh Migration; Total Extra-Peritoneal Repair
Introduction
The inguinal hernia repair is the most frequently performed procedure in general surgery. Laparoscopic repair is a reasonable alternative to traditional open technique for the treatment of hernia by the placement of mesh [1]. In the coming future this approach tends to become the gold standard procedure for the inguinal hernia. Early complications like superficial wound infection, seroma, hematoma, urinary retention and chronic pain are all reported and well known [2]. Late complications like mesh infection and mesh migration following laparoscopic approach are very low with reported incidence of mesh infection 0.1% to 0.2% only [3-5]. We report the first rare case of mesh migration through rectum following Total Extra Peritoneal (TEP) inguinal hernia repair.
Case Report
A 60 year old man presented to surgery emergency of our hospital with complaints of something coming out from anus since 2 days associated with vague lower abdominal discomfort. There was no associated history of fever, vomiting, abdominal distension, altered bowel habit or any abdominal trauma. Patient is a known diabetic and controlled on oral hypoglycemic drugs. The patient had underwent laparoscopic total extra peritoneal repair of bilateral inguinal hernia two years back from the current presentation, by using 2 mesh of size 7 × 15 cm polypropylene mesh with non-absorbable tacker fixation. Post-operative period was uneventful. On examination, he was afebrile, with stable hemodynamic parameters. There was no significant finding on per-abdominal examination. Per rectal examination revealed a foreign body (mesh) hanging out approximately 2 cm from anal verge (Fig.1).
Total leucocyte count was 8,600 and HbA1c was 5.70. Digital X-ray KUB region shows metallic tacker used for mesh fixation in right inguinal region (Fig 2). Contrast enhanced tomography was suggestive of well-defined hyperdensity noted in rectum with mild circumferential thickening of rectal wall and perirectal fat plane stranding with few air specks noted within the right lateral wall of rectum near the intraluminal hyperdensity (Fig 3).
Initially it was planned for performing per rectal examination under spinal anaesthesia and proceed for laparotomy accordingly, but it was found that mesh was lying loosely into the rectal canal without tacker. So the mesh was removed manually followed by per rectal examination which showed no signs of breach in the rectum (Fig 4). Postoperatively patient was kept nil per oral for one day. Recovery was uneventful and the patient was discharged subsequently. Patient was followed up for 1 year and he remained asymptomatic with no clinical evidence of recurrence of hernia or infection.
Figure 1: Foreign body hanging out from anus.
Figure 2: Non absorbable tackers in right inguinal region.
Figure 3: Abdominal CT scans showing hyperdensity in rectum.
Figure 4: Mesh after removal.
Discussion
Late complication related to mesh placement is rare. Mesh migration after laparoscopic inguinal hernia repair is just being encountered as an emerging complication. Only a hand full cases of mesh migration into urinary bladder, small bowel and large bowel after laparoscopic inguinal hernia repair have been reported so far [6-14]. In most of these reported cases, patients presented with abdominal complaints and underwent laparotomy with removal of mesh [7,8,14-16]. However, in contrast our patient did not have any abdominal complaint and painless migration of mesh occured and managed conservatively.
Few mechanisms responsible for painless mesh migration have been described by two authors in their study which can also be the possible explanation of painless presentation in our case [9,17]. Sha Liu, et al., proposed possible 4 mechanism of painless mesh migration in their study [9]:
- The foreign body reaction to mesh enables gradual movement of the mesh through the anatomic planes in the abdominal cavity, particularly along the paths of low resistance
- In some occasions, the mesh can be encapsulated by the omentum during its migration and create a channel into hollow organs along with inflammatory reaction and peristaltic bowel movement
- Gram-positive cocci are generally responsible for superficial wound infection and can further trigger the deeper infection. Bacterial biofilm can develop over the mesh due to chronic contamination by staphylococcus species, which results in painless mesh migration through the tissue
- Prosthetic mesh material decreases the formation of the mesothelial cell layer in peritoneal repaired defects, predisposing the irregular surface of mesh to be surrounded by scar tissue, thus the inflammation is localized
Agrawal A, et al., divided the mechanism of painless mesh migration into two type- primarily mechanical and secondarily due to erosion of surrounding tissue [17]. In primarily mechanism factor responsible for mesh migration is inadequate fixation or external displacing force which cause displacement into adjoining anatomical spaces. While secondary mechanism is slow and gradual movements of the mesh through trans-anatomical planes. These are secondary to foreign body reaction induced erosion, it is mainly dependant to a great extent on the nature of mesh biomaterial and on the type of fixation of the mesh, Thus the mesh initially may be displaced but later erode into adjacent tissue.
The exact mechanism causing mesh migration is still not clear, but few factors have been attributed for it like intra-op peritoneal breach, inadequate repair, inadequate mesh size, improper unfolding of mesh after placement, improper fixation of mesh with tackers, injury of visceral serosa by prosthetic mesh or tackers and strenuous activity in immediate post op period [7,18,19]. However in our case we could not ascertain any factor mentioned above responsible for mesh migration.
Thus our objective to report this case is to throw light on this possible, rarely reported complication of mesh placement following laparoscopic inguinal hernia repair. Although the exact mechanism and contributing factors responsible could not be ascertained but we hope that more reporting of such cases and further insight into the probable mechanism might benefit by implementing proactive or corrective measures to prevent such complication.
Conclusion
Case based reporting and study of detail of these cases gives us clue to recognising various possible mechanism and faulty technique of repair which leads to mesh migration as a complication of hernia repair and thus we suggest that all the cases of mesh migration should be reported and further research should be done and thereby taking necessary steps to prevent its incidence.
References
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Article Type
Case Report
Publication History
Received On: 04-12-2020
Accepted On: 31-12-2020
Published On: 08-01-2021
Copyright© 2020 by Pachauri A, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation: Pachauri A, et al. Migration of Mesh through Trans-Rectal Route: An Unusual Complication of Laparoscopic Inguinal Hernia Repair. J Surg Res Prac. 2020;2(1):1-7.
Figure 1: Foreign body hanging out from anus.
Figure 2: Non absorbable tackers in right inguinal region.
Figure 3: Abdominal CT scans showing hyperdensity in rectum.
Figure 4: Mesh after removal.
