VM17 - Is that Mesh?! Intraluminal Erosion of Inguinal Hernia Mesh into the Cecum Requiring Robotic Mesh Explant with Ileocecectomy

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Purpose/Background: We present the case of a 73 year old male with persistent, chronic groin pain 24 years after open inguinal hernia repair. After positive FIT testing, colonoscopy was performed revealing mesh that had eroded into his cecum. Subsequent CT confirmed mesh from his inguinal hernia repair had eroded into his cecum.

Methods/Interventions: A robotic assisted mesh explantation with en bloc ileocecectomy was performed. The abdomen was entered at Palmer's point using an Optiview trocar and insufflated to a pressure of 15mmHg. The cecum was noted to be adherent to the right myopectineal orifice. 4 additional robotic ports were placed under direct visualization. The patient was placed in Trendelenburg and the robot was docked.
Attention was turned to the right groin, and the cecum was slowly dissected off the right lower quadrant anterior abdominal wall. We started with a lateral to medial dissection. However, this dissection was very difficult due to the dense adhesions that had formed between the cecum and anterior abdominal wall. We transitioned to a medial to lateral dissection and performed a high ligation of the ileocolic pedicle using a Vessel Sealer. The right ureter was identified and preserved with the assistance of ICG instilled ureteral stents. We lifted the right colon mesentery off the retroperitoneum and then went back to our lateral dissection. The lateral dissection was again very difficult due to a thickened inflammatory rind. Two mesh plugs were noted to have eroded through the colon, one was located in the femoral space and secured with Prolene, while the other was in the direct space. These mesh plugs were removed en-bloc with the colon. Due to the dense adhesions between the colon, mesh, and epigastric vessels, the epigastric vessels had to be ligated. A colotomy was unavoidable but resulted in minimal spillage of stool. Once the cecum and mesh were dissected out of the groin, the terminal ileum and distal ascending colon were skeletonized. ICG fluorescence was used to confirm adequate perfusion to the terminal ileum and distal ascending colon. The terminal ileum and distal ascending colon were transected with blue loads of the 60 mm Surefire robotic stapler freeing the specimen. Another blue load of the stapler was used to perform an isoperistaltic side-to-side intracorporeal anastomosis, and a 3-0 V-Loc suture was used to close the common enterotomy in two layers.

Inspection of the right lower quadrant noted a small amount of pus. This was suctioned out. No residual abscess pocket was noted. A 15fr Blake drain was deep to the right groin and across the anastomosis. The specimen was extracted through a Pfannenstiel incision.

Results/Outcomes: The patient's post-operative course was notable for a prolonged ileus requiring NGT decompression and PPN supplementation. He was ultimately discharged on post-operative day 10. On post-operative day 14, he was seen in the clinic where he was found to be pain free for the first time in 24 years and otherwise doing very well.

Conclusion/Discussion: We present a difficult and interesting case of GI bleeding and chronic inguinal pain caused by erosion of mesh from inguinal hernia repair into the cecum. This patient was successfully treated with robotic assisted mesh explantation and en bloc ileocecectomy.