The use of meshes for abdominal wall repair has been widely accepted worldwide; however, serious complications may occur, such as superficial and deep surgical site infection¹, mesh migration, intestinal obstruction^2,3, penetration into intra-abdominal and extra-abdominal organs^1,4,5, and even mimic colorectal cancer⁶. These complications may occur between 6 months to 12 years after abdominal wall repair^1,4. The aim of this paper is to report a case of intestinal obstruction secondary to mesh migration into the peritoneal cavity in a previously asymptomatic patient who underwent left inguinal hernia repair 10 years prior to admission.

A 65-year-old male patient presented to the emergency department due to abdominal pain with an intensity of 10/10 that had lasted for 72 hours. The pain began in the epigastric region, radiated to the umbilical region, and was associated with nausea, vomiting, absence of bowel movements, inability to pass gas, and asymmetrical abdominal distension within the last 24 hours. He had a history of left inguinal hernia repair with mesh with the Rutkow Robbins technique 10 years prior to admission. He also reported chronic constipation and thrombocytopenia that was being managed by the department of hematology of our institution. The patient had no previous episodes of intestinal obstruction.

On physical examination, the oral mucosa appeared dry, and there were no signs of respiratory distress. The heart rate was slightly elevated, and no cardiac murmurs were detected upon auscultation. The abdomen was asymmetrically distended due to the presence of a hard, fixed mass on the left side of the abdomen, measuring 25 × 15 cm, which did not move with respiration. A scar was observed in the left inguinal region, but there was no bulging during the Valsalva maneuver. The abdominal examination revealed absent bowel sounds in all quadrants, preserved liver dullness, and a negative Blumberg’s sign. No other abnormalities were detected.

Upon admission, the patient presented with a heart rate of 110 beats per minute, respiratory rate of 14 breaths per minute, blood pressure of 110/70 mm Hg, and oxygen saturation of 96%. The laboratory tests showed hemoglobin level of 15 g/dL, platelet count of 27,000, white blood cell count of 7.05/mm3, with 70.7% of neutrophils. Additionally, the patient had prolonged prothrombin time (PT) and international normalized ratio (INR) (19.8 seconds), serum lactate level of 1.85, and normal serum electrolytes. A plain abdominal X-ray revealed an abdominal mass that could correspond to the small bowel on the left side of the abdomen (Fig. 1).

FIGURE 1 Abdominal mass on the left side of the abdomen corresponding to the small intestine. 

A midline incision was made to perform an exploratory laparotomy. In the left iliac fossa (Fig. 2A), a foreign body (5×5 cm cone-shaped polypropylene mesh) was discovered, as well as a cluster of intestinal loops measuring 20×16 cm, located 100 cm from the angle of Treitz and 100 cm from the ileocecal valve (Fig. 2B), with multiple firm adhesions to the sigmoid colon. The cluster was resected and a two-layer endto-end anastomosis was constructed. The left inguinal region was explored externally and internally, and as no recurrent hernial defect was identified, the cone-shaped polypropylene mesh was removed. The abdominal wall was closed with absorbable running suture. The pathology examination reported myxoid degeneration, edema and granulation tissue in the central portion of the small bowel. The patient evolved with favorable outcome. Clear liquid diet was started on postoperative day 4 when the patient recovered bowel motility, followed by a regular diet as tolerated. He was discharged on postoperative day 6.

FIGURE 2 A: Cone-shaped polypropylene mesh measuring 5×5 cm in the peritoneal cavity in contact with the intestinal loops. B: Cluster of intestinal loops measuring 20×16 cm, located 100 cm from the angle of Treitz and 100 cm from the ileocecal valve. 

Prosthetic materials have been widely used for hernia repair over the last four decades. However, these materials are not free of complications as local infections (3%), hematomas and seromas¹. Mesh migration has been reported to sites such as the

bladder^1,4, large intestine^2,3,6 or both⁵. The incidence of complications resulting from prosthetic material, such as foreign body reaction, migration, and perforation into the peritoneal cavity, is currently unknown.

The risk factors associated with mesh migration include lack of postoperative drainage, overfilled urinary bladder, inadequate fixation and external displacing forces, incomplete peritoneal repair, inflammation due to foreign body reaction¹, inadequate space for implantation of cone-shaped polypropylene mesh,

intra-abdominal placement, inadequate mesh size^2,3,6, and other factors related to patients’ performance status⁴.

Mesh migration can cause clinical manifestations that vary significantly and may occur from the first year to 20 years after surgery. These manifestations may vary depending on the affected site. Migration into the bladder may produce irritative urinary symptoms, recurrent infections, or hematuria^1,2,4. Intestinal obstruction, abdominal pain, and intestinal fistulas may develop in case of migration into the small and large intestine^2,3,5. Symptoms may also mimic neoplasms⁶.

Laboratory and imaging tests findings are variable and unspecific. Abdominal and pelvic radiographs can show signs of intestinal obstruction or radiopaque images. The abdominal computed tomography scan will show calcified foreign body or thickening of the bowel or bladder walls. Other examinations such as cystoscopy or colonoscopy should be considered in case an intraluminal lesion is suspected^1,6.

Endoscopic resection of the foreign body is the preferred treatment for mesh migration. If the mesh size is large and is severely or extensively adherent, surgical treatment is recommended¹.

In our case, although the patient had a history of chronic constipation, he had not previously experienced intestinal obstruction, abdominal pain, or weight loss. However, upon admission he presented with typical clinical signs of intestinal obstruction, in addition to marked abdominal asymmetry caused by a palpable mass. The plain abdominal X-ray showed an image suggestive of a probable volvulus. According to the literature, mesh that migrates into the peritoneal cavity can be mistaken for intra-abdominal neoplasms or sigmoid diverticulitis in imaging tests, or it may appear as a poorly defined mass⁵.

The use of mesh prostheses for inguinal hernia repair is widely accepted worldwide. As with all procedures, complications can arise, including mesh migration. This complication is rare, and its clinical presentation varies depending on the organ involved. Therefore, it is crucial to obtain a detailed medical record including the history of surgical procedures, and to consider the possibility of this complication.