Delayed Mesh Erosion into the Sigmoid Colon Following TEP Repair: A Case Report and Literature Review

Delayed Mesh Erosion into the Sigmoid Colon Following TEP Repair: A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Delayed Mesh Erosion into the Sigmoid Colon Following TEP Repair: A Case Report and Literature Review Ayako Yamazaki, Takeshi Nagahama, Mari Nakagawa, Chisato Okajima, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7342060/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Laparoscopic inguinal hernia repair is now standard, with totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques showing similar outcomes. TEP avoids intraperitoneal manipulation, reducing the risk of organ injury, but mesh erosion is an extremely rare complication. We report the first Japanese case―and the first worldwide presenting with hematochezia―of mesh erosion into the sigmoid colon six years after TEP repair in a 67-year-old man. Colonoscopy revealed mesh protrusion, and laparoscopic-assisted sigmoidectomy with mesh removal was performed. Recovery was uneventful. Despite no intraoperative peritoneal injury, chronic inflammation, compression necrosis, and unrecognized subclinical peritoneal injury are possible mechanisms. Literature suggests a lower incidence of mesh erosion after TEP than TAPP, but vigilance is warranted. Mesh erosion should be considered in patients with lower gastrointestinal bleeding long after TEP, and early imaging is advised for unexplained gastrointestinal or urinary symptoms. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction In recent years, laparoscopic surgery has become the standard approach for inguinal hernia repair. Among the available techniques, totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repairs have been reported to show no significant differences regarding operative time, wound-related complications, hospital stay, postoperative hernia recurrence, or chronic pain [ 1 – 3 ]. However, TEP repair offers the advantage of avoiding intraperitoneal manipulation, thereby reducing the risk of organ injury [ 4 ]. Consequently, cases of mesh erosion following TEP repair are rarely reported compared to TAPP repair [ 5 ]. To date, no cases of long-term organ injury due to TEP repair have been reported in Japan, and only eight cases have been reported worldwide [ 6 – 13 ]. Here, we present a rare case of mesh erosion into the sigmoid colon that occurred six years after TEP repair. While mesh erosion or migration following TEP repair is an extremely rare complication, it is a serious condition that warrants attention. This report aims to contribute to the understanding of this rare but significant event. Case Presentation A 67-year-old male patient presented to our outpatient clinic with complaints of hematochezia. He had undergone TEP repair for a left inguinal hernia at another hospital six years earlier. Colonoscopy revealed mesh protrusion into the sigmoid colon with associated luminal stricture (Fig. 1 ). He was referred to our department for further evaluation and treatment. A computed tomography (CT) scan demonstrated adhesion of the sigmoid colon to the abdominal wall in the left groin region (Fig. 2 ). Double-contrast barium enema (DCBE) confirmed that no other organs were involved, and no abscess cavity was present in the left inguinal area (Fig. 3 ). Based on these findings, the patient was diagnosed with mesh erosion into the sigmoid colon, and laparoscopic-assisted sigmoidectomy with mesh removal was performed. During surgery, the sigmoid colon was found to be firmly adherent to the abdominal wall in the left inguinal region, forming a single mass with the lateral edge of the mesh, requiring meticulous dissection (Fig. 4 ). The total operative time was 3 hours and 54 minutes, with an estimated blood loss of 270 ml. The length of the resected sigmoid colon was 15 cm. The removed mesh was identified as a PARIETEX Folding Mesh, 14 cm × 10 cm (Medtronic™) (Fig. 5 ). Histopathological analysis of the resected specimen revealed granulation tissue without evidence of diverticular disease, with no clear evidence regarding the cause of the perforation. The patient experienced prolonged inflammation due to the extensive dissection of the abdominal wall; however, his condition improved with conservative management. He was discharged on postoperative day 13 without complications, and at an 8-month follow-up, there was no evidence of hernia recurrence. Discussion Mesh erosion is a rare postoperative complication, particularly after TEP repair. Including the present case, only nine cases of mesh erosion following TEP repair have been reported (Table 1) [ 6 – 13 ]. The most commonly affected organs are the bladder and colon. This is the fifth reported case of mesh erosion involving the colon and the first to manifest as hematochezia. Other cases have been identified with symptoms such as constipation or inguinal swelling. In cases presenting with hematochezia or constipation, colonoscopy or CT imaging plays a crucial role in detecting mesh erosion. Although the exact cause of mesh erosion remains unclear, a review of the surgical video in this case revealed no technical errors, suggesting that mesh erosion can occur even when the procedure is performed correctly. In all reported cases, mesh removal was performed, and no instances of hernia recurrence have been documented. A 2015 Herniamed registry analysis of 17,587 patients who underwent laparoscopic hernia repair between 2009 and 2013 reported visceral complications in only 36 cases (0.2%), with mesh erosion after TEP repair presumed to be extremely rare [ 14 ]. Koliakos reported that the annual number of mesh erosion cases has remained relatively constant over the past 30 years since 1994, with laparoscopic repairs accounting for 47.3% of 57 cases in a systematic review, suggesting that some risk is inherent to the procedure [ 15 ]. The incidence of mesh erosion following TEP was approximately one-third that of TAPP [ 16 ], and Gossetti similarly reported rates of 12.1% in TEP and 39.1% in TAPP, indicating a lower risk with TEP [ 17 ]. The main difference between TEP and TAPP lies in the surgical field: TAPP requires peritoneal incision and closure, and inadequate closure can result in mesh exposure, increasing erosion risk [ 5 ]. While TEP avoids intraperitoneal mesh placement, closure is still necessary if peritoneal injury occurs. In our case, no peritoneal injury was documented, yet erosion developed, highlighting the multifactorial nature of this complication. We propose three hypotheses regarding the mechanism of mesh erosion into intraperitoneal organs. (1) Chronic inflammation: Persistent foreign body reactions can induce a prolonged inflammatory response, which may lead to gradual mesh migration and subsequent erosion into adjacent organs. (2) Compression and pressure necrosis: In the case we observed, the outer edge of the mesh was perforated, suggesting that mesh deformation and sustained pressure from surrounding structures could lead to tissue ischemia and eventual perforation. This highlights the importance of performing adequate dissection of the peritoneum in the lateral and dorsal directions before deploying the mesh. (3) Subclinical peritoneal injuries: Minor injuries undetected at the time of surgery may also provide a potential entry point for the mesh into the peritoneal cavity, further contributing to erosion. When mesh erosion occurs, removal is generally required [ 6 – 13 ]. For bladder or colon involvement, partial organ resection may be necessary. Although rare, mesh erosion should be considered in the differential diagnosis of unexplained gastrointestinal or urinary symptoms after TEP repair, and early imaging is recommended to facilitate timely diagnosis and management. Conclusion In conclusion, this case highlights that although TEP repair reduces the risk of intraperitoneal complications, mesh erosion into the sigmoid colon can still occur―even in the absence of peritoneal injury. It is essential for clinicians to be aware of this potential long-term complication and to consider mesh erosion in patients presenting with gastrointestinal or urinary symptoms post-hernia repair. Declarations Ethics declarations This study was conducted in accordance with the principles of the Declaration of Helsinki. Approval was obtained from the institutional review board (IRB) of Kudanzaka Hospital. Written informed consent to participate in the study and to the publication of clinical details and images was obtained from the patient. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution Ayako Yamazaki wrote this report. All authors reviewed the manuscript. Data Availability The datasets generated and analysed during the current study are available from the corresponding author on reasonable request. References Aiolfi A, Cavalli M, et al. Total extraperitoneal (TEP) versus laparoscopic transabdominal preperitoneal (TAPP) hernioplasty: systematic review and trial sequential analysis of randomized controlled trials. Hernia. 2021. https://doi.org/10.1007/s10029-021-02407-7. Balch JA, Crippen CND, Johnson-Mann CN, Read TE, Loftus TJ, et al. Safety of laparoscopic inguinal hernia repair in the setting of antithrombotic therapy. Surg Endosc. 2022. https://doi.org/10.1007/s00464-022-09360-1. Sivakumar J, Chen Q, Hii MW, Cullinan M, Choi J, Steven M, et al. Learning curve of laparoscopic inguinal hernia repair: systematic review, meta-analysis, and meta-regression. Surg Endosc. 2023. https://doi.org/10.1007/s00464-022-09760 Lomnicki J, Leszko A, Kuliś D, Szura M, et al. Current treatment of the inguinal hernia- the role of the totally extraperitoneal (TEP) hernia repair. Folia Med Cracov. 2018. https://doi.org/10.24425/fmc.2018.125076. Cardoso D, Rebanda J, Góis C, et al. Mesh migration and bowel perforation as a late complication of transabdominal preperitoneal laparoscopic hernia repair. Cureus. 2022. https://doi.org/10.7759/cureus.32683. Chowbey PK, et al. Mesh migration into the bladder after TEP repair: a rare case report. Surg Laparosc Endosc Percutan Tech. 2006. https://doi.org/10.1097/01.sle.0000202185.34666.f1. Tamam M, Yavuz HS, Hacimahmutoglu S, Mulazimoglu M, Kacar T, Ozpacaci T. Direct radionuclide cystography imaging in colovesical fistula due to inguinal hernia operation complication. Ann Nucl Med. 2009. https://doi.org/10.1007/s12149-009-0276-y. Han HJ, Kim CY, Choi SB, Kwak JM, Lee SI. Sigmoid colon fistula following totally extraperitoneal hernioplasty: an improper treatment for mesh infection or iatrogenic injury? Hernia. 2010. https://doi.org/10.1007/s10029-010-0700-1. Hamouda A, Kennedy J, Grant N, Nigam A, Karanjia N. Mesh erosion into the urinary bladder following laparoscopic inguinal hernia repair; is this the tip of the iceberg? Hernia. 2010. https://doi.org/10.1007/s10029-009-0539-5. Aggarwal S, Praneeth K, Rathore Y, Waran V, Singh P. Laparoscopic management of mesh erosion into small bowel and urinary bladder following total extra-peritoneal repair of inguinal hernia. J Minim Access Surg. 2016. https://doi.org/10.4103/0972-9941.169956. Sandhu AS, Kumar A, Kumar BN. Mesh erosion into urinary bladder following laparoscopic inguinal hernia repair. J Minim Access Surg. 2017. https://doi.org/10.4103/0972-9941.195579. Mulleners G, Olivier F, Abasbassi M. A minimally invasive treatment of an asymptomatic case of mesh erosion into the caecum after total extraperitoneal inguinal hernia repair. Acta Chir Belg. 2019. https://doi.org/10.1080/00015458.2017.1419918. Patel M, Shenoy C, Nagarajan G, Chandiramani V. Mesh migration into the sigmoid colon after total extraperitoneal hernioplasty– Report of a case and review of the literature. J Minim Access Surg. 2020. https://doi: 10.4103/jmas.JMAS_122_19. Köckerling F, Bittner R, Jacob DA, et al. TEP versus TAPP: comparison of the perioperative outcome in 17,587 patients with a primary unilateral inguinal hernia. Surg Endosc. 2015. https://doi.org/10.1007/s00464-015-4150-9. Koliakos N, Papaconstantinou D, et al. Intestinal erosions following inguinal hernia repair: a systematic review. Hernia. 2021. https://doi.org/10.1007/s10029-020-02324-1. Koliakos N, Papaconstantinou D. Intestinal erosion rate following transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) inguinal hernia repair: does the surgical approach matter? Author ’s reply. Hernia. 2021. https://doi.org/10.1007/s10029-021-02418-4. Gossetti F, D’Amore L, Annesi E, Bruzzone P, Bambi L, et al. Mesh-related vis ceral complications following inguinal hernia repair: an emerging topic. Hernia. 2019. https://doi.org/10.1007/s10029-019-01905-z. Table Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":8871,"visible":true,"origin":"","legend":"\u003cp\u003eColonoscopy. Mesh protruding into the sigmoid colon with stricture.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7342060/v1/947c0d9866067f96d113630e.jpeg"},{"id":93541246,"identity":"cbd258c4-4863-4704-9d80-360b22ad71a6","added_by":"auto","created_at":"2025-10-15 02:29:33","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":12150,"visible":true,"origin":"","legend":"\u003cp\u003eCT scan. Adhesion of the sigmoid colon to the abdominal wall in the left groin area.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7342060/v1/df17ac18c5d53779590d0a6a.jpeg"},{"id":93541256,"identity":"c47edb00-3fe6-4d62-af76-79374cdc314e","added_by":"auto","created_at":"2025-10-15 02:29:33","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":8231,"visible":true,"origin":"","legend":"\u003cp\u003eX-ray. There were no other organs involved and no abscess cavity in the left groin.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7342060/v1/87d6fdc380ea1ea357ddc315.jpeg"},{"id":93541248,"identity":"d7ac27e3-c2fe-46f4-acf4-c2e66300884c","added_by":"auto","created_at":"2025-10-15 02:29:33","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":13737,"visible":true,"origin":"","legend":"\u003cp\u003eOperation. The sigmoid colon was adhered to the abdominal wall in the left groin area.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7342060/v1/86cf33c82cc38de54ae6ff84.jpeg"},{"id":93542263,"identity":"e4484c59-2238-4519-9486-1c95394b53f3","added_by":"auto","created_at":"2025-10-15 02:37:33","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":27938,"visible":true,"origin":"","legend":"\u003cp\u003eThe removed mesh. The mesh was identified as a PARIETEX Folding Mesh, 14 cm × 10 cm (Medtronic™).\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7342060/v1/c08ed4571fc045a5edefe371.jpeg"},{"id":96363100,"identity":"ee50be9a-bbfd-44dc-8bd8-de31f1cca19c","added_by":"auto","created_at":"2025-11-20 10:04:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":391006,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7342060/v1/c471ba25-13b8-417a-9bf1-24eef5d694dd.pdf"},{"id":93541245,"identity":"050d1603-e057-4074-9a54-91b71c8d345d","added_by":"auto","created_at":"2025-10-15 02:29:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":78663,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7342060/v1/ebde2caf6e0d6e657840900f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Delayed Mesh Erosion into the Sigmoid Colon Following TEP Repair: A Case Report and Literature Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn recent years, laparoscopic surgery has become the standard approach for inguinal hernia repair. Among the available techniques, totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repairs have been reported to show no significant differences regarding operative time, wound-related complications, hospital stay, postoperative hernia recurrence, or chronic pain [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, TEP repair offers the advantage of avoiding intraperitoneal manipulation, thereby reducing the risk of organ injury [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, cases of mesh erosion following TEP repair are rarely reported compared to TAPP repair [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. To date, no cases of long-term organ injury due to TEP repair have been reported in Japan, and only eight cases have been reported worldwide [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Here, we present a rare case of mesh erosion into the sigmoid colon that occurred six years after TEP repair. While mesh erosion or migration following TEP repair is an extremely rare complication, it is a serious condition that warrants attention. This report aims to contribute to the understanding of this rare but significant event.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 67-year-old male patient presented to our outpatient clinic with complaints of hematochezia. He had undergone TEP repair for a left inguinal hernia at another hospital six years earlier. Colonoscopy revealed mesh protrusion into the sigmoid colon with associated luminal stricture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). He was referred to our department for further evaluation and treatment. A computed tomography (CT) scan demonstrated adhesion of the sigmoid colon to the abdominal wall in the left groin region (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Double-contrast barium enema (DCBE) confirmed that no other organs were involved, and no abscess cavity was present in the left inguinal area (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Based on these findings, the patient was diagnosed with mesh erosion into the sigmoid colon, and laparoscopic-assisted sigmoidectomy with mesh removal was performed. During surgery, the sigmoid colon was found to be firmly adherent to the abdominal wall in the left inguinal region, forming a single mass with the lateral edge of the mesh, requiring meticulous dissection (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The total operative time was 3 hours and 54 minutes, with an estimated blood loss of 270 ml. The length of the resected sigmoid colon was 15 cm. The removed mesh was identified as a PARIETEX Folding Mesh, 14 cm \u0026times; 10 cm (Medtronic\u0026trade;) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Histopathological analysis of the resected specimen revealed granulation tissue without evidence of diverticular disease, with no clear evidence regarding the cause of the perforation. The patient experienced prolonged inflammation due to the extensive dissection of the abdominal wall; however, his condition improved with conservative management. He was discharged on postoperative day 13 without complications, and at an 8-month follow-up, there was no evidence of hernia recurrence.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMesh erosion is a rare postoperative complication, particularly after TEP repair. Including the present case, only nine cases of mesh erosion following TEP repair have been reported (Table\u0026nbsp;1) [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The most commonly affected organs are the bladder and colon. This is the fifth reported case of mesh erosion involving the colon and the first to manifest as hematochezia. Other cases have been identified with symptoms such as constipation or inguinal swelling. In cases presenting with hematochezia or constipation, colonoscopy or CT imaging plays a crucial role in detecting mesh erosion. Although the exact cause of mesh erosion remains unclear, a review of the surgical video in this case revealed no technical errors, suggesting that mesh erosion can occur even when the procedure is performed correctly. In all reported cases, mesh removal was performed, and no instances of hernia recurrence have been documented.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eA 2015 Herniamed registry analysis of 17,587 patients who underwent laparoscopic hernia repair between 2009 and 2013 reported visceral complications in only 36 cases (0.2%), with mesh erosion after TEP repair presumed to be extremely rare [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Koliakos reported that the annual number of mesh erosion cases has remained relatively constant over the past 30 years since 1994, with laparoscopic repairs accounting for 47.3% of 57 cases in a systematic review, suggesting that some risk is inherent to the procedure [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The incidence of mesh erosion following TEP was approximately one-third that of TAPP [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and Gossetti similarly reported rates of 12.1% in TEP and 39.1% in TAPP, indicating a lower risk with TEP [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe main difference between TEP and TAPP lies in the surgical field: TAPP requires peritoneal incision and closure, and inadequate closure can result in mesh exposure, increasing erosion risk [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While TEP avoids intraperitoneal mesh placement, closure is still necessary if peritoneal injury occurs. In our case, no peritoneal injury was documented, yet erosion developed, highlighting the multifactorial nature of this complication.\u003c/p\u003e\u003cp\u003eWe propose three hypotheses regarding the mechanism of mesh erosion into intraperitoneal organs.\u003c/p\u003e\u003cp\u003e(1) Chronic inflammation: Persistent foreign body reactions can induce a prolonged inflammatory response, which may lead to gradual mesh migration and subsequent erosion into adjacent organs.\u003c/p\u003e\u003cp\u003e(2) Compression and pressure necrosis: In the case we observed, the outer edge of the mesh was perforated, suggesting that mesh deformation and sustained pressure from surrounding structures could lead to tissue ischemia and eventual perforation. This highlights the importance of performing adequate dissection of the peritoneum in the lateral and dorsal directions before deploying the mesh.\u003c/p\u003e\u003cp\u003e(3) Subclinical peritoneal injuries: Minor injuries undetected at the time of surgery may also provide a potential entry point for the mesh into the peritoneal cavity, further contributing to erosion.\u003c/p\u003e\u003cp\u003eWhen mesh erosion occurs, removal is generally required [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. For bladder or colon involvement, partial organ resection may be necessary. Although rare, mesh erosion should be considered in the differential diagnosis of unexplained gastrointestinal or urinary symptoms after TEP repair, and early imaging is recommended to facilitate timely diagnosis and management.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this case highlights that although TEP repair reduces the risk of intraperitoneal complications, mesh erosion into the sigmoid colon can still occur―even in the absence of peritoneal injury. It is essential for clinicians to be aware of this potential long-term complication and to consider mesh erosion in patients presenting with gastrointestinal or urinary symptoms post-hernia repair.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics declarations\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Approval was obtained from the institutional review board (IRB) of Kudanzaka Hospital. Written informed consent to participate in the study and to the publication of clinical details and images was obtained from the patient.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAyako Yamazaki wrote this report. All authors reviewed the manuscript.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAiolfi A, Cavalli M, et al. Total extraperitoneal (TEP) versus laparoscopic transabdominal preperitoneal (TAPP) hernioplasty: systematic review and trial sequential analysis of randomized controlled trials. Hernia. 2021. https://doi.org/10.1007/s10029-021-02407-7. \u003c/li\u003e\n\u003cli\u003eBalch JA, Crippen CND, Johnson-Mann CN, Read TE, Loftus TJ, et al. Safety of laparoscopic inguinal hernia repair in the setting of antithrombotic therapy. Surg Endosc. 2022. https://doi.org/10.1007/s00464-022-09360-1. \u003c/li\u003e\n\u003cli\u003eSivakumar J, Chen Q, Hii MW, Cullinan M, Choi J, Steven M, et al. Learning curve of laparoscopic inguinal hernia repair: systematic review, meta-analysis, and meta-regression. Surg Endosc. 2023. https://doi.org/10.1007/s00464-022-09760 \u003c/li\u003e\n\u003cli\u003eLomnicki J, Leszko A, Kuliś D, Szura M, et al. Current treatment of the inguinal hernia- the role of the totally extraperitoneal (TEP) hernia repair. Folia Med Cracov. 2018. https://doi.org/10.24425/fmc.2018.125076. \u003c/li\u003e\n\u003cli\u003eCardoso D, Rebanda J, G\u0026oacute;is C, et al. Mesh migration and bowel perforation as a late complication of transabdominal preperitoneal laparoscopic hernia repair. Cureus. 2022. https://doi.org/10.7759/cureus.32683. \u003c/li\u003e\n\u003cli\u003eChowbey PK, et al. Mesh migration into the bladder after TEP repair: a rare case report. Surg Laparosc Endosc Percutan Tech. 2006. https://doi.org/10.1097/01.sle.0000202185.34666.f1. \u003c/li\u003e\n\u003cli\u003eTamam M, Yavuz HS, Hacimahmutoglu S, Mulazimoglu M, Kacar T, Ozpacaci T. Direct radionuclide cystography imaging in colovesical fistula due to inguinal hernia operation complication. Ann Nucl Med. 2009. https://doi.org/10.1007/s12149-009-0276-y. \u003c/li\u003e\n\u003cli\u003eHan HJ, Kim CY, Choi SB, Kwak JM, Lee SI. Sigmoid colon fistula following totally extraperitoneal hernioplasty: an improper treatment for mesh infection or iatrogenic injury? Hernia. 2010. https://doi.org/10.1007/s10029-010-0700-1. \u003c/li\u003e\n\u003cli\u003eHamouda A, Kennedy J, Grant N, Nigam A, Karanjia N. Mesh erosion into the urinary bladder following laparoscopic inguinal hernia repair; is this the tip of the iceberg? Hernia. 2010. https://doi.org/10.1007/s10029-009-0539-5. \u003c/li\u003e\n\u003cli\u003eAggarwal S, Praneeth K, Rathore Y, Waran V, Singh P. Laparoscopic management of mesh erosion into small bowel and urinary bladder following total extra-peritoneal repair of inguinal hernia. J Minim Access Surg. 2016. https://doi.org/10.4103/0972-9941.169956. \u003c/li\u003e\n\u003cli\u003eSandhu AS, Kumar A, Kumar BN. Mesh erosion into urinary bladder following laparoscopic inguinal hernia repair. J Minim Access Surg. 2017. https://doi.org/10.4103/0972-9941.195579. \u003c/li\u003e\n\u003cli\u003eMulleners G, Olivier F, Abasbassi M. A minimally invasive treatment of an asymptomatic case of mesh erosion into the caecum after total extraperitoneal inguinal hernia repair. Acta Chir Belg. 2019. https://doi.org/10.1080/00015458.2017.1419918. \u003c/li\u003e\n\u003cli\u003ePatel M, Shenoy C, Nagarajan G, Chandiramani V. Mesh migration into the sigmoid colon after total extraperitoneal hernioplasty\u0026ndash; Report of a case and review of the literature. J Minim Access Surg. 2020. https://doi: 10.4103/jmas.JMAS_122_19. \u003c/li\u003e\n\u003cli\u003eK\u0026ouml;ckerling F, Bittner R, Jacob DA, et al. TEP versus TAPP: comparison of the perioperative outcome in 17,587 patients with a primary unilateral inguinal hernia. Surg Endosc. 2015. https://doi.org/10.1007/s00464-015-4150-9. \u003c/li\u003e\n\u003cli\u003eKoliakos N, Papaconstantinou D, et al. Intestinal erosions following inguinal hernia repair: a systematic review. Hernia. 2021. https://doi.org/10.1007/s10029-020-02324-1. \u003c/li\u003e\n\u003cli\u003eKoliakos N, Papaconstantinou D. Intestinal erosion rate following transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) inguinal hernia repair: does the surgical approach matter? Author \u0026rsquo;s reply. Hernia. 2021. https://doi.org/10.1007/s10029-021-02418-4. \u003c/li\u003e\n\u003cli\u003eGossetti F, D\u0026rsquo;Amore L, Annesi E, Bruzzone P, Bambi L, et al. Mesh-related vis ceral complications following inguinal hernia repair: an emerging topic. Hernia. 2019. https://doi.org/10.1007/s10029-019-01905-z.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7342060/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7342060/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLaparoscopic inguinal hernia repair is now standard, with totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques showing similar outcomes. TEP avoids intraperitoneal manipulation, reducing the risk of organ injury, but mesh erosion is an extremely rare complication. We report the first Japanese case―and the first worldwide presenting with hematochezia―of mesh erosion into the sigmoid colon six years after TEP repair in a 67-year-old man. Colonoscopy revealed mesh protrusion, and laparoscopic-assisted sigmoidectomy with mesh removal was performed. Recovery was uneventful. Despite no intraoperative peritoneal injury, chronic inflammation, compression necrosis, and unrecognized subclinical peritoneal injury are possible mechanisms. Literature suggests a lower incidence of mesh erosion after TEP than TAPP, but vigilance is warranted. Mesh erosion should be considered in patients with lower gastrointestinal bleeding long after TEP, and early imaging is advised for unexplained gastrointestinal or urinary symptoms.\u003c/p\u003e","manuscriptTitle":"Delayed Mesh Erosion into the Sigmoid Colon Following TEP Repair: A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 02:29:28","doi":"10.21203/rs.3.rs-7342060/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f613fae7-d6ee-4e72-aa4e-3114f73dcf29","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T09:24:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-15 02:29:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7342060","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7342060","identity":"rs-7342060","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}