title: Sigmoid to scrotal fistula secondary to mesh erosion: a rare complication of inguinal hernia repair in a patient on anticoagulation.
abstract: BACKGROUND
  Few 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.
  
  
  METHODS
  A 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.
  
  
  CONCLUSIONS
  Sigmoid 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.
authors.affiliation: Department of Surgery, Division of General Surgery, American University of Beirut-Medical Center, P.O. Box 11-0236/K3, Riad El Solh, 1107 2020, Beirut, Lebanon.
authors.forename: Jad A
authors.initials: JA
authors.lastname: Degheili
authors.affiliation: Department of Surgery, Division of General Surgery, American University of Beirut-Medical Center, P.O. Box 11-0236/K3, Riad El Solh, 1107 2020, Beirut, Lebanon.
authors.forename: Maen
authors.initials: M
authors.lastname: Aboul Hosn
authors.affiliation: Department of Surgery, Division of General Surgery, American University of Beirut-Medical Center, P.O. Box 11-0236/K3, Riad El Solh, 1107 2020, Beirut, Lebanon.
authors.forename: Mustapha
authors.initials: M
authors.lastname: El Lakis
authors.affiliation: Department of Surgery, Division of General Surgery, American University of Beirut-Medical Center, P.O. Box 11-0236/K3, Riad El Solh, 1107 2020, Beirut, Lebanon. ah05@aub.edu.lb.
authors.forename: Ali H
authors.initials: AH
authors.lastname: Hallal
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D004322:Drainage; D004868:Equipment Failure; D005402:Fistula / Q000209:etiology* / Q000601:surgery; D006406:Hematoma / Q000209:etiology; D006552:Hernia, Inguinal / Q000601:surgery*; D006801:Humans; D007412:Intestinal Fistula / Q000209:etiology* / Q000601:surgery; D010535:Laparoscopy; D008297:Male; D010537:Peritoneum / Q000601:surgery; D011183:Postoperative Complications / Q000601:surgery; D012611:Scrotum / Q000601:surgery; D012772:Shock, Septic / Q000209:etiology; D012810:Sigmoid Diseases / Q000209:etiology* / Q000601:surgery; D013526:Surgical Mesh
chemical_list: D000925:Anticoagulants