INTRODUCTION

INGUINAL HERNIA REPAIR is the most commonly per-formed surgical procedure.1 Laparoscopic repair is one

of the treatment options recommended by the NationalInstitute of Clinical Excellence (NICE) for inguinal her-nia repair.2 The transabdominal preperitoneal (TAPP)and total extraperitoneal (TEP) are two methods for thelaparoscopic repair of inguinal hernia. The advantages of

the procedures are a shorter hospital stay and a quickerrecovery, as compared to the open method. However, thecomplications of vascular and visceral injuries are higherwith laparoscopic methods.1,3 One particular long-termcomplication is the migration and erosion of mesh intoadjacent viscera. In this paper, we present the case of a66-year-old gentleman with mesh erosion into the cae-cum who underwent a laparoscopic repair of a right in-guinal hernia (TAPP) 10 years ago.

JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUESVolume 17, Number 5, 2007© Mary Ann Liebert, Inc.DOI: 10.1089/lap.2006.0135

Case Report

Mesh Erosion into Caecum Following Laparoscopic Repair ofInguinal Hernia (TAPP): A Case Report

and Literature Review

RUP GOSWAMI, MBBS, MS, DNB, FRCS, MOHAMMED BABOR, MBBS,and AKINYEDE OJO, MBBS, FRCS

ABSTRACT

Repair of inguinal hernia is the most commonly performed surgical procedure. Both open and lap-aroscopic methods are accepted modalities of surgical treatment. Transabdominal preperitoneal (TAPP)and total extraperitoneal (TEP) are the two types of laparoscopic repair of the inguineal hernia. Themain advantages of laparoscopic repair, as compared to open repair, are a shorter hospital stay and aquicker recovery to normal activities. However, laparoscopic repairs are associated with a higher inci-dence of visceral and vascular injuries. One particular complication is the migration and erosion ofmesh into the adjacent viscera. Although the total numbers of cases are small, compared to the totalnumbers of inguinal hernia repairs, they are important, as they often presented with a diagnosticdilemma. Most of the mesh migrations reported in the literature involves the urinary bladder. In thispaper, we present a case of erosion of mesh into the caecum. The patient (a 66-year-old male) under-went TAPP repair of a right inguinal hernia in 1996 with polypropelene mesh. He also underwent anopen appendicectomy in 1980. During the laparoscopic repair, he was found to have multiple intra-ab-dominal adhesions. He presented with intermittent diarrhea, for which he was investigated, and a be-nign caecal lesion was found. He was initially managed conservatively. However, his symptoms per-sisted and he underwent a right hemicolectomy in February 2006 in our hospital. The offending lesionwas found to be the prolene mesh having eroded into the caecum.

Department of General Surgery, King George Hospital, Ilford, United Kingdom.

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CASE REPORT

A 66-year-old male patient presented with intermittentdiarrhea with a background of heavy drinking in 2003.His past medical history included an appendicectomy in1980 and the laparoscopic repair of a right inguinal her-nia (TAPP) in 1996. Clinically, there was no recurrenceof the hernia and the examination was otherwise unre-markable. He was investigated as an outpatient. Ultra-sound and computed tomography scans (Fig. 1) of his ab-domen were unhelpful. A barium meal follow-throughrevealed a suspicious lesion in the caecum. He underwenta colonoscopy, which revealed a lesion in the caecum(Fig. 2A), which was biopsied. The histology report ex-cluded any malignancy and he was managed conserva-tively.

However, he continued to be symptomatic and under-went a repeat colonoscopy. The previous lesion was seenagain (Fig. 2B) and an attempted removal failed. He de-veloped portal pyemia and a liver abscess, which re-sponded favorably to conservative management.

A clinical decision to undertake a right hemicolectomyto remove the lesion was made, and the patient under-went a right hemicolectomy through a transverse incisionin February 2007. During the operation, the caecum wasfound to be stuck to the anterior abdominal wall withdense adhesions, which required a sharp dissection. Thelesion was dissected out separately (Fig. 3), which wasfound to be the mesh used for the hernia repair.

The patient made a slow but uneventful recovery, punc-tuated with minor wound collection and was discharged onthe eleventh postoperative day. He has subsequently beenfollowed up as an outpatient and is symptom free.

DISCUSSION

Laparoscopic repair of the inguinal hernia is associ-ated with mesh migration and erosion into the intra-ab-

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FIG. 1. Computed tomography scan pictures of the right in-guinal region showing a thickened caecal wall with adjacentsurgical clips. The lower frame is an expanded view of the cae-cal region.

FIG. 2. (A) Initial colonoscopic view of the caecal lesion and(B) a follow-up colonoscopic view of the caecal lesion after anattempted removal by colonoscopy.

A

B

MESH EROSION INTO CAECUM AFTER TAPP

dominal viscera. The factors responsible for this migra-tion remain obscure. Most of the mesh migrations re-ported in the literature involve the urinary bladder.4–8 Mi-gration and erosion of mesh into the bowel has also beenreported.9,10 We found 1 case of mesh migration and ero-sion into the splenic flexure of the colon 6 months afterthe laparoscopic repair of a bilateral inguinal hernia(TAPP), which was removed by a colonoscopy. The meshhad migrated from the right inguinal region. The authorsthought that a partial inclusion of the caecum or ileumduring the closure of the peritoneal window was proablyresponsible.9 One study reported a case of small intesti-nal obstruction resulting from mesh migration and con-sequent adhesion between the mesh and the terminalileum requiring a laparotomy, following an open meshrepair of a right inguinal hernia 3 years before.11

The case report described in this paper is that of mesherosion into the caecum following the laparoscopic re-pair (TAPP) of a right inguinal hernia. Although therehave been reports of migration or erosion into the largebowel or bladder in the literature, we have not comeacross mesh erosion into the caecum in the English-lan-guage literature.

A review of his operative note revealed that there weremultiple intra-abdominal adhesions in the operating field.Mesh was stapled into position, and the peritoneal win-dow was closed with staples. It is possible that a previ-ous appendicectomy, by causing adhesions, predisposedthe patient to further adhesion between the mesh and theunderlying viscera (i.e., the caecum). In addition to localadhesions in the region of the hernia, it is also likely thattechnical errors, such as inadequate closure of the peri-toneal window and accidental inclusion of intra-abdom-

inal viscera during the closure of the peritoneal window,are potential causes for adhesion and the consequent ero-sion of mesh into the adjacent viscera. We found 1 studythat investigated the possibility of sitting posture in theimmediate postoperative period as a potential cause ofmesh displacement.12 This was a small study, however,and no effect was seen.

CONCLUSIONS

It is not clear which laparoscopic method (TAPP orTEP) is superior to the other, as systematic reviews andcomparative studies are inconclusive.13,14 Further ade-quately powered studies with long-term follow-ups andsubgroup analyses are required to define the factors re-sponsible for mesh migration and erosion.

REFERENCES

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9. Celik A, Kutun S, Kockar C, Mengi N, Ulucanlar H, CetinA. Colonoscopic removal of inguinal hernia mesh: Reportof a case and literature review. J Laparoendosc Adv SurgTech A 2005;15(4):408–410.

10. Benedotti M, Albertario S, Neibel T, Bianchi C, TinozziFP, Moglia P, Arcidiaco M, Tinozzi S. Intestinal perfora-tion as a long-term complication of plug and mesh inguinalhernioplasty: Case report. Hernia 2005;9(1):93–95.

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FIG. 3. Mesh covered with calcified fibrosis after operativeremoval.

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11. Ferrone R, Scarone C, Natalini G. Late complication ofopen inguinal hernia repair: Small bowel obstructioncaused by intraperitoneal mesh migration. Hernia 2003;7(3):161–162.

12. Choy C, Shapiro K, Patel S, Graham A, Fezli G. Investi-gating a possible cause of mesh migration during totallyextraperitoneal (TEP) repair. Surg Endosc 2004;18(3):523–525.

13. Arregui M, Young S. Groin hernia repair by laparoscopictechniques: Current status and controversies. World J Surg2005;29:1052–1057.

14. Wake BL, McCormack K, Fraser C, et al. Transabdominalpreperitoneal (TAPP) versus totally extraperitoneal (TEP)

laparoscopic techniques for inguinal hernia repair. In TheCochrane Database of Systematic Reviews, Issue 1,2005:CD004703.

Address reprint requests to:Rup Goswami, MBBS, MS, DNB, FRCS

Department of General SurgeryKing George Hospital

Barley LaneIlford, IG3 8YA

United Kingdom

E-mail: rupgoswami01@hotmail.com

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