Chronic abdominal pain secondary to mesh erosion into cecum following incisional hernia repair: a case report and literature review
The patient is a 56-year-old female with a past medical history of hypertension, morbid obesity, and uterine fibroids. She had a history of abdominal surgery with two cesarean sections, total abdominal hysterectomy, and bilateral salpingooophorectomy. Five months after her last surgery in 1996, the patient was re-admitted with a large incisional hernia. She had open hernia repair with inlay polypropylene mesh under general anesthesia. Her post-operative course was uncomplicated. In general, polypropylene is cheap, available readily and is usually first choice for most hernias. It causes intense scarring, which is what is desired for repair of hernias.\nApproximately 14 years (June 2010) after hernia repair, the patient presented to the Emergency Department complaining of intermittent abdominal pain rated 6/10 starting at right lower quadrant and migrating upwards and diffusely over the entire abdomen, associated with 2-3 episodes of nausea/ week. She had felt this pain on and off for the past 2 years but came to the Emergency Department because she felt it was worsening. She denied any other complaints. She was passing gas and having bowel movements. All lab work was normal. Computed tomography (CT) scan of abdomen and pelvis was unremarkable. Physical exam showed moderate tenderness at right lower quadrant but was otherwise benign. Prior screening colonoscopy showed diverticulosis but was otherwise unremarkable. Repeat colonoscopy was performed on this admission which showed mesh in the cecum. In light of the patient’s past history of incisional hernia repair with polypropylene mesh, this finding was consistent with partial migration of the previous surgical mesh into the cecum and mesh was intact. The mesh appeared to have eroded into the lumen, but there was no enterocutaneous fistula or any other enteric fistula. This would have been evident by clinical exam and CT scan. The patient had no external leakage of stool or gas to suggest an enterocutaneous fistula, and she did not have peritoneal signs to suggest an enteric leak into the abdomen ().\nMesh migration often results in significant bleeding or a fistula and requires operation. However, based on the patient’s minimal symptoms, morbid obesity, and probability of significant surgical morbidity (postoperative wound infection, recurrent hernia, fistula, etc.), we elected to observe. The patient was discharged with instructions to return in case of significant bleeding or increased, disabling pain. Surgery would be a better choice but the operation would be complicated; she was morbidly obese and had had multiple hernia repairs in the past. Her mesh migration was in the right lower quadrant, a difficult area to repair hernias because mesh fixation around the iliac bone is difficult. After initial presentation, she was advised to be followed up as she was minimally symptomatic from it and had no bleeding. The operation would have involved removing the mesh, removing the cecum, re-anastamosing the bowel and then repairing the hernia with a biologic mesh, so that the mesh would not get infected. A two-stage operation might have to be done since bowel resection would have contaminated the field.