Hernia
https://doi.org/10.1007/s10029-018-1759-3
CASE REPORT
Mesh migration into an inguinal hernia sac following a laparoscopic
umbilical hernia repair
H. B. Cunningham1 · S. Kukreja1 · S. Huerta1 
Received: 15 July 2017 / Accepted: 10 March 2018
© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2018
Introduction
According to the National Survey of Ambulatory Surgery
(NSAS), 1.2 million abdominal wall hernias were repaired
in 2003 [1, 2]. The NSAS showed that 66.4 and 15.1% were
inguinal and umbilical hernia (UH) repairs, respectively [2].
Thus, UHs are the second most common abdominal wall
hernias and together with groin and incisional hernia repairs
constitute the most frequent operations performed by general
surgeons [3, 4].
UHs in the obese population have been gaining attention
as the incidence of obesity increases [1]. In obese patients,
there is an increase in opening pressure of 0.07 mmHg pro-
portionally to every 1.0 kg/mm2 in BMI posing an increased
strain on the umbilicus leading to a higher incidence of UH
[5]. Thus, the higher the BMI, the more likely an UH might
develop. Obese patients with a BMI of 30–39 kg/m2 have a
2.6 odds ratio of developing an UH, which increases to 5.2
for patients with a BMI greater than 60 kg/m2 [6]. While
there is compelling evidence documenting increased likeli-
hood of developing UH and incarceration in obese patients
[6] due to elevated intra-abdominal pressure [5], the inci-
dence of recurrence and the appropriate method for repair
in obese patients remain unclear.
A strategy to reduce recurrence and complications from
UHR has advocated the laparoscopic approach [7]. A study
comparing mesh repair of UH in obese patients via an open
approach vs. laparoscopy found that laparoscopy was asso-
ciated with a lower rate of SSI (26.0 vs. 4.0%; p < 0.05),
but recurrence was similar in both groups [8]. Another
small study found that of 76 UH repairs (32 repaired lap-
aroscopically, 24 primarily, and 20 open with mesh), no
recurrences occurred with the laparoscopic approach, but a
* S. Huerta
Sergio.Huerta2@va.go
1
Surgical Service (112), VA North Texas Health Care System,
4500 S. Lancaster Road, Dallas, TX 75216, USA
20% recurrence with the open mesh repair (p < 0.001) [9].
Wright’s group examined 30, 20, and 66 UH repairs with
mesh placed laparoscopically, open mesh repair and tissue
repair and found 0, 5, and 6 recurrences, respectively (p = ns)
[10]. Criteria for the repair of UHs via laparoscopy have
not been firmly established and cost remains an important
component of further assessment.
There is no question that the introduction of laparoscopy
has been a major landmark in surgical innovation. However,
this has also led to unusual complications; and while rare,
recognition is important to guide preventative measures
and guide management strategies. Mesh migration follow-
ing hernia repair is a usual, but critical clinical problem that
might lead to severe complications.
In the present report, we discuss a patient who underwent
a laparoscopic umbilical hernia repair which was compli-
cated by mesh migration into an inguinal hernia sac leading
to a symptomatic right inguinal hernia and a recurrence of
the umbilical hernia.
Methods
The clinical records of the patient who underwent opera-
tive intervention at the VA North Texas Health Care System
were reviewed from the electronic medical record system.
Informed consent was obtained from the patient for the pub-
lication of this case report.
Case report
A 63-year-old, obese (BMI = 31.9 kg/m2), African American
man underwent a laparoscopic umbilical hernia repair in
November of 2016. His past medical history was signifi-
cant for hypertension, hyperlipidemia, and a cerebrovascular
accident without motor deficits. He also had a history of
prostate cancer which was treated with radiation therapy.
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He presented to clinic with a 2.0 cm, mildly symptomatic
umbilical hernia. He had undergone a computed tomography
(CT) scan of the abdomen and pelvis as part of his follow-up
for prostate cancer a few months prior to the repair (Fig. 1).
At that time, a small fat containing umbilical hernia was
noted with small bilateral fat-containing inguinal hernias
(Fig. 1b, d).
He presented to clinic with complaints of discomfort and
occasional pain at the umbilicus. Options for repair were
presented to the patient and he elected to proceed with lapa-
roscopic repair.
The hernia had been repaired laparoscopically. Entry
into the peritoneal cavity was accomplished via an 11-mm
port in the left upper quadrant under direct visualization
with the camera in place. Pneumoperitoneum was achieved
at 15 mmHg. Three additional 5-mm ports were placed one
in the right lower quadrant and two in the left abdomen.
A 12-cm circular, non-woven, microfiber, polypropylene
mesh ­(SURGIMESH®; ­ASPIDE®MEDICAL, France) was
Fig. 1  Pre-operative computed tomography scan prior to laparoscopic umbilical hernia repair which shows an umbilical hernia: panels A and B
(arrows). An symptomatic right inguinal hernia is also noted: panels C and D (arrows)
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introduced through the 11-mm port. Four trans-fascial
0-vicryl sutures were utilized to fix the mesh at four points
in equal distances. This was followed by tacking the mesh
with absorbable tacks ­[Securestrap® absorbable strap fixa-
tion device (Ethicon, USA)] at 1-cm equal distances from
each other.
At the end of the operation, 10 mL of 0.25% bupiv-
acaine with epinephrine (1:200,000) was infiltrated along
the port incision sites. He was discharged home following
the recovery, the same day of surgery. Oral opioids were
prescribed (hydrocodone bitartrate and acetaminophen;
NORCO) for the postoperative period. He recovered well
from this operation and was seen in clinic 2 weeks postop-
eratively, at which time he had no complaints.
He then returned to clinic 5 months after the laparo-
scopic umbilical hernia repair with a primary concern of
swelling of the right groin associated with mild discom-
fort. A CT scan was obtained (Fig. 2) which demonstrated
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Fig. 2  Computed tomography scan after laparoscopic repair of umbilical hernia. A recurrence of the hernia is noted: panel A (arrow). There is a
large right inguinal hernia: panel C (arrow). Mesh is noted in the hernia sac: panel D (arrow)
a recurrent umbilical hernia and migration of the prior
mesh into the inguinal canal.
He underwent surgical intervention for the repair of
the right inguinal hernia and extirpation of the mesh
6/29/2017. The inguinal hernia repair was performed
under general anesthesia. He received preoperative anti-
biotics per surgical care improvement protocol and insti-
tutional guide lines. The open approach consisted of a skin
incision down to the aponeurosis of the external oblique
with electrocautery. A stab incision was made in the
aponeurosis of the external oblique and extended toward
the superficial inguinal ring with Metzenbaum scissors.
The spermatic cord was isolated at the level of the pubic
tubercle and encircled with a Penrose drain. Inspection
of the cord revealed a large indirect hernia sac along its
anteriomedial side. Isolation of the sac was performed all
the way down to the neck of the hernia. Gentle palpation
of the hernia sac demonstrated no sliding component. The
sac was opened and the mesh was found to be floating in a
pool of fluid within the sac. The fluid was drained and the
mesh readily extracted (Fig. 3). The sac was closed with
3-0 Vicryl and reduced. Inspection of the floor revealed
that the transversalis fascia was intact. However, we
elected to enforce the floor by bringing the conjoin tendon
to the shelving edge of the inguinal ligament with 0-poly-
dioxanone (PDS) sutures in a figure of eight fashion. The
external oblique aponeurosis was closed with a 2-0 Vicryl
suture, the Scarpa’s fascia with 3-0 Vicryl and the skin
with 4-0 Monocryl. At the end of the operation, 10 mL
of 0.25% bupivacaine with epinephrine (1:200,000) was
infiltrated along the hernia incision. He was discharged to
home following recovery the same day after the operation.
Oral opioids were prescribed (hydrocodone bitartrate and
acetaminophen; NORCO) for the postoperative period.
There were no intra-operative complications and he was
doing well at a two-week postoperative visit in the surgery
clinic. Review of the electronic medical records demon-
strated that he had been seen (9/25/2017) in the urology
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Fig. 3  Intra-operative images show a fluid-filled hernia sac: panel A (arrow). The extracted mesh is shown in panels B, C, and D
clinic as part of his follow-up for prostate cancer. He had
no complaints related to his hernias. Physical exam dem-
onstrated no recurrence.
Discussion
Laparoscopic and open approaches to an umbilical hernia
should be viewed as complementary strategies, not compet-
ing. No strategy has demonstrated superiority over another
(i.e. mesh vs. primary tissue repair; laparoscopic vs. open)
for the repair of an UH. While complications from the lapa-
roscopic approach of an UH are rare, they are substantially
consequential. Anytime mesh is placed in a body cavity; it
has the potential to migrate anywhere within that cavity. It
can migrate along anatomical planes (typically the result of
inappropriate fixation) or violate anatomical planes during
the migration (which typically involves infection or inflam-
mation and it takes longer to occur) [11].
Mesh migration from the repair of abdominal wall hernias
has been previously reported following repair of incisional
hernias [12–18], umbilical hernias [19–21], and inguinal
hernias [11, 22–27]. Mesh migration has been observed both
with the laparoscopic [11, 28, 29] and open [12, 14, 17,
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30, 31] approach. It has occurred with multiple mesh types
such as polypropylene [16], ventral composite mesh [19],
proline [24], ePTFE [32], plug-in mesh [33], Bard 3D max
mesh [34] and others [22, 26]. It seems that no technique or
method is immune to this complication. For instance, for the
repair of inguinal hernias, mesh migration has been observed
with the TEP approach [35], the TAPP technique [23], the
plug and patch open repair [33], the Lichtenstein repair [36]
and the Stoppa technique [37]. The most common reports are
from inguinal hernia repair (IHR) [11] into the bladder and
small bowel, mainly after laparoscopic approach. Incisional
hernia repair with mesh complicated by migration has also
been described in several case reports [15–18]. Presentations
have included small bowel obstruction [19–24], perforation
[25], and volvulus [26, 27].
Agrawal and Avill [11] first proposed possible mecha-
nisms of mesh migration dividing them into two main
causes: (1) primary mesh migration is the result of inap-
propriate fixation. In this setting, mesh migration occurs
along anatomical planes along paths of least resistance. (2)
Secondary mesh migration, on the other hand, is slow and
gradual and might occur through trans-anatomic spaces. In
this case, the presence of inflammatory granulation tissue
has been found at the site of migration and suggests that
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erosion of the mesh into adjacent tissue might have been
the cause of mesh displacement [29]. In the case presented
herein, since the migration occurred early after the repair
and along anatomical planes, inappropriate fixation appears
to be the most likely cause.
The present case is the third documented case. In another
case, a composite mesh migrated to the colon after a supra-
umbilical hernia repair [19]. In a second case, migration
occurred into small bowel following repair of a UH with a
non-anchored Marlex mesh plug (Marlex Pharmaceuticals,
Inc., New Castle, DE). Ultimately, this led to a small bowel
obstruction 13 years after the repair [20]. The true incidence
of mesh migration is not known [19] as this is likely an
underreported phenomenon.
It is important to recognize the possibility of mesh migra-
tion in order to eradicate this complication. Adequate fixa-
tion, elimination of contact between bowel and synthetic
mesh, and closure of violated peritoneum might eliminate
this surgical catastrophe.
Compliance with ethical standards  16. Falk GA, Means JR, Pryor AD (2009) A case of ventral hernia
Conflict of interest  The authors declare no conflict of interest.
Ethical approval  All procedures performed in the studies involving
human participates were in accordance with the ethical standards of
the institution and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Human and animal rights  The patient provided informed consent for
the publication of this article.
Informed consent  Informed consent was obtained from this patient for
the publication of this case.
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