S1644 Mesh Migration Mimicking a Diverticular Abscess: A Rare Complication of Hernia Repair

Abstract

INTRODUCTION: Inguinal herniorrhaphy with mesh is one of the most common surgical procedures done around the world. A rare complication of mesh repair is the migration of the mesh into adjacent abdominal structures, leading to fistulae and subsequently a diverse set of symptoms. We present a case of mesh erosion into the sigmoid colon presenting as an abdominal abscess. CASE DESCRIPTION/METHODS: A 62 year-old male with history of previous inguinal repairs (right and left elective hernia repairs were twenty and two years ago, respectively, without bowel resection or complications) presented with sharp and intermittent left lower quadrant abdominal pain near his left groin for three to four days. He did not appear in extremis; vital signs were within normal limits and a comprehensive metabolic panel and complete blood count were unremarkable. CT of the abdomen and pelvis suggested a left anterior pelvic abscess. A clinical diagnosis of a diverticular abscess was made, though no underlying diverticulosis was identified on imaging and the patient had not had a prior colonoscopy. The patient was administered intravenous piperacillin-tazobactam, transitioned to oral antibiotics, and discharged after an unremarkable hospital course, with plan for outpatient colonoscopy to rule out malignancy as an etiology for his diverticulitis. On outpatient colonoscopy, patient was noted to have mesh extruding into the sigmoid colon without adjacent mucosal inflammation. He had a repeat CTAP, which demonstrated a contained left pelvic wall/abdominal wall abscess communicating with the sigmoid colon. Colorectal surgery was consulted and the patient ultimately underwent an open sigmoidectomy and mesh explanation with repair of the left inguinal hernia with Viceryl mesh. DISCUSSION: Mesh migration into adjacent abdominal viscera is a rare complication that can present early to many years after the procedure. These can manifest in a variety of presentations, from mild abdominal pain to life threatening conditions, such as bowel obstruction, peritonitis, and as in our case, a colonic fistula which was presumed to be a diverticular abscess, with actual etiology only detected on colonoscopy done to rule out underlying malignancy. Early recognition is important to avoid superimposed infection, fibrosis, and further complications, as well as to lead to appropriate management, which is often surgical repair. This case highlights the importance of recognizing mesh erosion in patients with abdominal pain with history of hernia repair.Table 1.: Initial basic metabolic panel and complete blood count labs were unremarkable, as notedFigure 1.: The patient had a repeat CT Abdomen/Pelvic with contrast, which demonstrated a contained left pelvic-abdominal wall abscess communicating with the sigmoid colon (arrow).Figure 2.: On outpatient colonoscopy, patient was noted to have a foreign body, consistent with mesh extruding into the sigmoid colon without adjacent mucosal inflammation. No diverticulosis was seen.