IT'S A MESH IN THESE BOWELS: DELAYED CASE OF A DECADE LONG MESH ERODING INTO SMALL BOWEL CAUSING OBSTRUCTION AND INTRAPERITONEAL SEPSIS.

Objectives:

Background:
The use of mesh has become standard practice for hernia repair as it helps produce a tension-free repair of the fascial defect and also reduces hernia recurrence rates. Such repairs can cause seromas, hematomas, and increase the risk of infection which are often managed conservatively. Rarely severe complications can arise such as mesh migration causing intestinal obstruction, perforation and intra- abdominal abscess or ECF. We present a case of transmural mesh migration from the abdominal wall into the small bowel presenting as small bowel obstruction and intra-abdominal sepsis.


Case Description:
A 66 year old female with a history of an umbilical hernia repair with mesh 10 years prior presented with a one week history of a worsening periumbilical bulge. Associated symptoms included nausea, vomiting, decreased appetite, and increasing erythema over the periumbilical area. The patient had not passed flatus or had a bowel movement in 3-4 days. She was hypotensive and tachycardic on arrival and in florid septic shock requiring active resuscitation. Computed tomography imaging showed a 5 x 3 x 4 cm air and fluid collection in the anterior abdominal wall with an abnormal subjacent hydrostatic small-bowel loop near the periumbilical inflammation. She underwent an emergent exploratory laparotomy and was found to have an ventral hernia with erosion of previous hernia mesh into the small bowel causing perforation, obstruction, abscess and feculent peritonitis.


Discussion:
Mesh migration after an abdominal hernia repair is rare, with a rate of about 2.7%. While the pathogenesis of mesh migration is not completely understood, it is thought that depending on the material used, a postoperative inflammatory process can cause an opening for the mesh to enter into the abdominal cavity from the peritoneum. The mesh then interacts with the omentum and the inflammatory process there can cause adhesions, which has the potential to cause small bowel obstruction or an enterocutaneous fistula or in rare cases erosion into the small bowel lumen resulting in obstruction and intra-abdominal sepsis.

Conclusion:
The incidence of mesh migration is significantly lower than hernia recurrence rate after repair without mesh. The benefit of repairing hernias with mesh outweighs the cons of performing a repair without. However, surgeons should be aware of such potential complications when using mesh and be familiar with the presenting symptoms.

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