Sigmoid to scrotal fistula secondary to mesh erosion: a rare complication of inguinal hernia repair in a patient on anticoagulation

Abstract

BackgroundFew reports from the medical literature have presented severe mesh-related complications following laparoscopic repair of inguinal hernia. One of these complications is being mesh erosion into bowel, resulting in fistulous tract with subsequent abscess formation.Case presentationA 75-year-old patient, status post laparoscopic bilateral inguinal hernia repair, and on anticoagulation for dual prosthetic heart valves, presented with a unique case of sigmoid to scrotal fistula, post mesh erosion, resulting in sepsis. The patient presented in septic shock, necessitating an individualized surgical approach. Given the septic picture of our patient, the surgical approach was truncated. Initially the sepsis from the scrotum was drained and debrided. A watermelon seed was noted in the scrotum. After stabilization, the second stage approach was performed, were a laparotomy was performed, followed by division of the sigmoid to internal ring fistula, and reperitonealization of the mesh. Mesh removal was delayed as the risk of bleeding into the peritoneum was high, once anticoagulation needed to be resumed. Because of a persistent wound sinus tract, several months later, the mesh was removed, in a third stage, from an inguinal incision. Albeit meticulous dissection and homeostasis, a postoperative extraperitoneal inguinal hematoma developed, as expected, on day 2, once anticoagulation was resumed.ConclusionSigmoid to inguinoscrotal fistula is a rare, yet serious, complication of mesh infection and erosion. This can be obviated by preventing serosal tear, and proper peritonealization of the mesh. Fistulectomy alone with primary repair turned out to be a valid approach in our patient. Retaining the mesh could be an alternative for avoiding bleeding in patients on anticoagulation; despite that a persistent indolent infection and sinus tract will necessitate mesh removal afterwards.

Colocutaneous Fistula Formation Following Inguinal Hernia Repair: A Case Series

“…The role of diverticulosis in the fistula formation remains unclear. There are cases in which diverticular disease coexisted with mesh-related fistulae, although no direct implication could be noted [7][8][9][10][11]. However, the presence of diverticula is speculated to be a risk factor [9].…”

“…In the second case, the mesh had eroded through the wall of the sigmoid colon eventually leading to the formation of a colocutaneous fistula, requiring open laparotomy with sigmoidectomy and en bloc excision of the adherent mesh. In such cases, where mesh erosion coexists with diverticular disease, diagnostic dilemmas may arise, nevertheless, surgery effectively addresses both the colocutaneous fistula and the required excision of the inflammatory mass containing the mesh [8][9][10][11][12].…”

Enterocutaneous fistula secondary to mesh erosion of bowel: a late complication of polypropylene mesh use in ventral hernia repair

“…A Degheili et al reported a sigmoid to scrotal fistula post inguinal hernia repair in 2015. 10 We found just one comparative study about early and late-onset prosthetic mesh infection published in 2015 by Wengcheng Kong et al 11 Very few case reports or research articles were found on ECF following open incisional hernia repair. [12][13][14] For prevention of fistulas, Losanoff et al proposed using tissue impervious composite material in close proximity of bowel.…”

A Narrative Review on Polypropylene Mesh Complications in Inguinal Hernia Repair - is Titanized Mesh an Option?

“…Pore size, filament structure, and the surface of the mesh structure are decisive in how much adhesion is produced when the mesh is placed in the vicinity of the bowel. Microporous structure at the side of the bowel and additional surface [58] in composite meshes provide a temporary barrier against adhesion. However, the absorbable coatings may be degraded in the short term [59].…”